by Ronald L. Neer, D.D.S.
Temporomandibular Joint problems (TMJ) are diversely classified as intracapsular and extracapsular conditions. Intracapsular being in the joint structures like the mandibular condyle, the articular disc and the glenoid fossa. Extracapsular being in the muscles, tendons and ligaments surrounding and connecting to the TM joints and mandible itself.
INTRACAPSULAR
These disorders are featured by structural alterations of the temporomandibular joint which interfere with the form and function and frequently produce pain. They are made up of four groups of disorders:
- Developmental Disorders: These problems occur as a result of abnormal development of the joint.
- Diseases: These consist of degenerative arthritis, rheumatoid arthritis and neoplasms.
- Injuries: These occur when trauma is induced to the jaw directly or indirectly like in Whiplash.
- Internal derangements: These occur when the physiologic relationship of the condyle, disc, and fossa have been lost.
Internal problems constitute the vast majority of this group. In a typical derangement the disc assumes a position forward of the condyle due to a problem with the discal attachment. When this is present, a click is heard during opening movements and usually a softer click is heard in the closing of the mandible. If this is left untreated, it may result in a closed lock and alterations in form occur and the onset of degenerative osteoarthritis usually occur. With this comes the onset of pain often severe, and the likelihood of surgical intervention becomes more probable. These are problems associated with an abnormal bite due to various reasons like tooth loss movement, improper or inaccurate or dental restorations, cogenital malocclusions or trauma that alters the relationship of the way that the teeth fit together. These symptoms can be as follows:
HEADACHE: Headache is the most common symptom of a TMJ problem. Although any area of the head may be affected, usually the TMJ headache is located in the temples and back of the head. Also, a displaced disc in the TMJ may cause pain in the joint and is referred into the temples, forehead or neck. They can be so severe that they are treated with little relief for migraine headaches. EAR PAIN: Due to the close location of the ears and the TMJs, an injury to the TMJ caused ear problems. Symptoms like pain, fullness, stuffiness or even hearing loss can occur even though medical evaluation of the ear is normal. FACIAL PAIN: Facial pain can show on our faces even though the TMJ does not hurt. Facial pain may be deep or on the surface in the skin. The skin might even become sensitive to the touch or air blowing across it. Neurologists are usually contacted in these instances. EYE SYMPTOMS: There can be pain behind the eyes or pressure build up and no evident eye problem detected from the eye doctor. Also there can be unusual eye deviations to the left, right, up or down that occur. TEETH: A damaged TMJ may cause tooth pain due to the change in the bite or fit of the teeth. The teeth may become sensitive to temperature changes especially cold. Patients see the dentist and no cause can be found and frequently unnecessary root canals and extractions are performed to rid a patient in pain. Whiplash Injuries - Dentistry's Role Whiplash injuries, one of the most frequent types of trauma encountered in Personal Injury Practice, often have an overlooked but significant TMJ aspect.
How the Injury Occurs
Whiplash the most common trauma, occurs when the muscles which attach to the front of the neck and chest do not have time to relax. Consequently, these muscles anchor the jaw but not the head by holding it still so that the mouth opens too wide while the head snaps back. The TMJ joints dislocate when they are pulled out of the socket and forcefully pushed against the back of the socket when the head whips forward. Since the head and neck are forced to move beyond their normal range of motion, the muscles, ligaments and discs are damaged with an injury. The key thing to note is that most of the time there is a TMJ injury when there has been a Whiplash injury but symptoms may not be felt until hours or months after the injury. Since soft tissue (discs, ligaments, and muscles) damage does not show up well on screening x-rays, it is difficult to immediately see structural damage. Common medical observation does not provide a conclusive diagnosis. Many times the patients nor the health care providers suspect damage to the jaw joints, muscles and ligaments. When this condition is not recognized and properly treated it can become the dominant medical problem causing various disabilities and legal issues. When this type of injury occurs, the symptoms can include some or more of the following:
Headaches-usually in temples and back of head and neck
Face or jaw pain
Ear pain, fullness or stuffiness, ringing or even loss of hearing
Pain behind the eyes or unexplained eye disorders
Dizziness/Balance problems
Limited mouth opening or locking (opened or closed)
Difficulty closing teeth together
Unexplained teeth pain
Clicking, popping, or pain in jaw joint
Difficulty swallowing
Unusual fatigue or lack of energy
Neck, shoulder, back pain or stiffness When your clients have sustained a whiplash injury, there is frequently an unrecognized associatedT MJ injury as well, and these should not be overlooked in order to secure proper compensation for your client. Tests and examinations can be done to identify damage and therapy needed to treat the TM joints. The key to successful treatment is a highly trained dentist and accurately obtained records. Many dentists do not treat these problems so a blanket referral of "see your dentist" usually will not be appropriate. It is imperative to refer your clients to a TMJ specialist.
TMJ TREATMENT MODALITIES
Early treatment is very important and cannot be overstated. TMJ problems can advance in stages and grow progressively worse. Thus, a minor problem now could become a major source of pain in the future. Additionally, chances of successful therapy increase substantially the earlier treatment is accomplished.
After diagnosing the problem, a variety of treatments may be recommended depending on the extent of correction needed. Initial phases of treatment are aimed to eliminate the TMJ pain resulting from the actual problem. In the second stage, the actual treatment to correct the problem is implemented.
Medicines/Muscle Stimulation/Ultrasound: These may be prescribed to alleviate the pain before and during the actual treatment.
Trigger Point Injections: This is the injection of anesthetic into muscle to eliminate muscle spasm.
Splint/Jaw Repositioner Appliances: This is a mouth appliance that is custom made to fit between the patient's upper and lower teeth. It is not only used in diagnosis, but they are also used as treatment to temporarily eliminate the bite: disharmony and resulting pain. Then once we have achieved a state of muscle relaxation and an acceptable level of patient comfort then we can determine which forms of permanent treatment are necessary to maintain long term comfort.
Occlusal Equilibration: The tops of the teeth are reshaped in this procedure. This is done to alleviate pressure on individual teeth. The reshaping procedure has been found to be the solution for many conditions which cause discomfort in the head, neck, and shoulders and the breakdown of dental structures. This can be likened to a pebble in your shoe and your foot adapts to that pebble and you may limp. As with atooth too high for comfort, the jaw also adapts to the uncomfortable tooth fit but develops muscle pain. During equilibration the high tooth is reshaped for a better fit and resulting muscle relaxation.
Occlusal Restorations: This involves the placement or construction of teeth by means of crowns, bridges, implants, inlays, onlays, partial dentures or just routine restorations to build the bite to a more permanent, healthy, relationship.
About Ronald Neer, MD
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