TMJ and Headaches page 7-DoctorSpiller.com

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The Treatment of TMJ

If you have managed to read through all 6 of the preceding pages, you probably realize that there is a stark difference between the diagnosis of the two broad categories of TMD.

The majority of TMD patients (I like to refer to them as TMJ Lite) have the muscle related symptoms of headache, ear ache, neck ache, jaw pain and inability to remain open for long periods, or tooth related symptoms of sensitivity to cold, a tendency to bony destruction in periodontal disease, an increase in the decay caused by sugar habits, along with some difficulty in chewing hard foods.

The minority of patients (heavy duty TMJ) have organic problems with the joint itself caused by external trauma or by the constant trauma to the joints produced by the parafunctional habits.  The trick is to differentiate between the two categories, and at times the difference is not always especially obvious. The good news is that conservative treatment usually works well on both categories of patients, and so differentiation between the the two categories is not always necessary.

The treatment of TMD Lite

The Bruxing Guard\

bruxingguardThe key to treating these patients is to reduce the patient’s tendency to clench and grind her teeth. TMJ fades away if the patient does not grind or clench his or her teeth. Therefore, the trick to treating the symptoms of TMJ are to find a way to keep the patient from griding or clenching.  The most common, and least expensive treatment for TMD is the construction of a hard acrylic bruxing guard (and now flexible plastics are being used as well).  These are horseshoe shaped plastic appliances which fit over (usually) the top teeth and have a smooth surface on the underside so the lower teeth can slide over the plastic without resistance.  This prevents the teeth from locking together, and relieves a lot of the force placed on the teeth and joints.  If an appliance like this is worn long enough, the bruxing habit may eventually disappear altogether, which would be the ideal treatment goal if it always happened.  Unfortunately, bruxing guards still allow the patient to clench against the guard.  Since clenching is associated with overuse of the temporalis muscle, patients may still experience headaches even though they wear their guard religiously.

The bite adjusted (deprogrammed) Bruxing guard

Bruxing guards work even better if they are built so that when the lower teeth contact the plastic, the joints are forced to sit in their most relaxed positions.  This position places the condyle (the ball of the joint)  in its most relaxed position within the Glenoid Fossa.  This position can be determined quite easily by a simple trick called deprogramming in which a piece of plastic is inserted over the top front teeth that does not allow the posterior teeth to make any contact.  Usually, within an hour or so of wearing one, the jaw has “dropped” into a relaxed position with the joints in a more desirable position.  A bite registration is taken with the deprogramming device (deprogrammer) in place so the new bruxing guard can be built to the new bite-adjusted jaw position which corresponds to a more physiologically acceptable joint position.  Deprogramming has an additional advantage in that if it works, it will relieve the symptoms very quickly and can be worn until the deprogrammed bruxing guard can be built.

The main disadvantage with this treatment modality is that the patient is stuck wearing a bruxing guard whenever he is likely to be bruxing.  In addition, patients still can clench against any bruxing guard.  Thus, even a properly balanced deprogrammed bruxing guard will not reliably relieve all tension or migraine headaches, although it generally will reduce their frequency.   The major advantage to this treatment modality is that it is not expensive and can often relieve long standing pain that has been a major hindrance to a normal lifestyle for years!

Deprogrammers

The concept of deprogramming is based on the reflexive relaxation of the lower jaw when the back teeth are not permitted to engage.  The various muscles that open and close the jaw learn and remember the level of contraction needed to perform their movements in a coordinated, comfortable way.  They learn which positions of these muscles cause pain, and which don’t, and store all the information in your brain in the form of “engrams” which are similar to automatic, unconscious computer programs that your body uses each time you open or close your mouth.  In persons with TMJ, these movements can be quite complex.

The idea behind the deprogrammer is that it makes it impossible for the back teeth to come together, and thus clenching and bruxing (grinding) can’t happen.  If a deprogramming jig is worn for a long enough time, the brain will forget its clenching and grinding engrams, and eventually the patient learns not to clench or grind even without the device in place.

NtiThe most popular device currently marketed to dentists is called the NTI (for Nocireceptive Trigeminal Inhibition).  It is a proprietary device which fits over the top front teeth and accomplishes the same thing as the butterfly deprogrammer.  Many dental offices are now beginning to treat TMJ using this deprogrammer, and dental labs now make these devices. Any dentist wishing to use deprogramming to treat TMD should check with their lab to see if they fabricate them.

An older device is called a Lucia Jig.  It fits over the two top front teeth like the NTI.  It is fabricated “freehand” by the dentist out of cold cured acrylic or light cured composite. Lucia jigs have been in use by dentists for treating TMJ since the late 1960’s. They are the “quick and dirty” way to temporarily treat severe cases while waiting for the lab to fabricate the NTI.  Since they generally fit over the two upper central incisors, prolonged use of these jigs could cause unwanted movement of the incisors, which is why they are only used temporarily.

Deprogrammers have become more and more accepted as a permanent treatment modality for TMD.  The main advantage of a deprogrammer over a bruxing guard is that the patient is unable to clench the teeth against a deprogrammer.  Thus tension headaches are effectively treated with a deprogrammer while bruxing guards are not as reliable for this purpose since the patient can still clench the teeth against a bruxing guard.  For the same reason, deprogramming has been accepted by the medical community as an acceptable treatment modality for many cases of migraine headache.  The main disadvantage of a deprogrammer as a permanent treatment modality is the appearance of the teeth while wearing one.

A couple of notes to dentists

Originally, I believed that a deprogrammer, if worn continuously, could cause intrusion of the lower incisors.  Over the years, I have noticed that this has not happened as I expected, even in those patients who continue to wear the deprogrammer for years on end. This may be due to the fact that the deprogrammer is rarely worn during the day when the patient is talking or otherwise in contact with other people.  It may also be due to the fact that the deprogrammer is really accomplishing is working as planned; actually deprogramming the patient and stopping bruxing, even when the patient stops wearing it.

It becomes easier to visualize the relationship between bruxing or clenching and tooth movement when you think about patients who lose a temporary crown prior to insertion of the final restoration.  These patients fall into two categories.   Some present with fairly rapid drifting of the prepared tooth (or the adjacent teeth) while others seem to suffer very little tooth movement.  The difference between patients in these two categories results from their bruxing habits.  Bruxing seems to mobilize the bone and allows for the rapid drifting of teeth, even if the tooth in question is not in occlusion.

I have built flat plane bruxing guards for patients, and then discovered that they did not prevent the symptoms of headache or jaw aching.  When this happens, I can often bring about relief by placing a small anterior disoccluding element on the bruxing guard using light cured composite.

How to find a dentist who treats TMD using deprogramming techniques

At present it can be difficult to find dentists who treat TemporoMandibular joint Disfunction using this fairly simple and effective approach.  Since the advent of the NTI device, and its easy availability through dental laboratories, many dentists are using this device for their TMD patients.  In some cases, patients may find a dentist simply by calling different offices to see who is using the NTI.

Another trick you could try is to call dental labs in your area and ask if they make the NTI and which dentists offices order them.

The Prosthodontic solution

If you are rather well off financially,  you can have a dentist rebuild all your teeth so that their new positions guide the joints into the proper alignment.  This is called the prosthodontic solution because the dentists most likely to recommend this treatment are specialists called prosthodontists who make a lot of crowns, bridges and implants. The proper alignment is determined mechanically in these cases, and with the joint discrepancy corrected, there is less of a tendency on the part of the patient to brux the teeth.  The main disadvantage to this form of treatment, is that the new teeth will still tend to lock together, and if the bruxing habits continue, as they frequently do, the patient may still have all the muscular symptoms he started with.  The advantage is that now the joints are in a more correct alignment so the joint damaging process may be halted, and the teeth usually look great.  It seems to have worked splendidly for Burt Reynolds.

The Orthodontic solution

A third treatment modality is orthodontics.  In this case, the natural teeth are moved into a correct position that allows the joints to sit correctly in their sockets.  The correct position is determined by a science called cephalometrics which is a subcategory of diagnostic x-rays.  This treatment has the same advantages and disadvantages as noted in the discussion of the prosthodontic solution above.  It has the further advantage of leaving you with all-natural teeth that are nice and straight, but it has the added disadvantage of taking a long time to accomplish. (Interestingly, in the long run, this treatment modality is much less expensive than the prosthodontic solution, and is more likely to break the bruxing habits.)

The use of drugs in the treatment of TMD

Pain medications

Pain meds are useful to the extent that the drugs are used to reduce pain in acute situations.  The most useful drugs for TMD pain are non-steroidal-anti-inflammatories (NSAIDS) such as Advil or Motrin combined with Tylenol.  These drugs are freely available over the counter and are non addictive.  Prescription versions such as Lodine are often longer lasting and better for chronic situations.  Narcotics are never indicated for use in the treatment of TMJ for more than 24 hours.  The addicting properties of narcotics combined with the intense personality types associated with TMD make make them a dangerous choice for long term use!!!

Muscle relaxants

Muscle relaxants such as Flexaril, Parafon and Robaxin are often used to relieve the muscle tension that leads to bruxing, especially for nighttime use.  More addicting varieties of muscle relaxants such as Valium are useful for nighttime use only for limited periods of acute muscular activity.

In the past, injections of corticosteroids directly into the affected joint have been used to bring about relief.  This does, in fact, appear to work for fairly prolonged periods.  Unfortunately, these injections tend to produce degenerative changes in the structures within the joint, and ultimately cause more problems than they cure.

The “all-natural” cures

In the final analysis, no matter what the physical parameters of the joints, teeth and muscles happen to be, the “root cause” of most TMD pain involves the bad habits of bruxing (grinding and clenching the teeth).  Even severe TMD produced by traumatic events are generally temporary unless the patient grinds and clenches, in which case the damage is made worse, and the pain persists.  If you can find any method of stopping the habits, you can stop the disease, and this includes anything that can work on the mind as well as on the body.  It is a very rare person indeed who can simply stop by sheer force of will power.  These habits have deep psychological roots, and are done unconsciously anyway.  In the past, psychoanalysis, group therapy and even past life therapy have been known to bring about relief.

When real pain and physical damage to the body are caused by habits which have a psychological basis (and stress is ultimately a psychological reaction to the strain of everyday living) the disease is said the have “psychosomatic” origins.  This term is vastly misunderstood by the public at large.  It does NOT mean that the problem is “all in your mind”.  It means that your body is connected to your brain, and the way your body reacts to the various stimuli it encounters daily depends to a large extent on the way your mind chooses to direct it.

The treatment of severe TMD and internal joint deterioration

Dental students, hygiene students and assistants who want to know more about the technical aspects of occlusion should also see my companion pages on occlusion and the internal arrangement of the TMJ.
Actually, the same treatments that are used for the treatment of the less severe forms of TMD often work quite well for patients with real organic joint damage.  In general, forcing the joints into a physiologically correct position when the teeth are together, as discussed above, frequently stops the deterioration cold, and sometimes  allows for healing of the damage already done, provided that the patient’s bruxing habits are under control.  (See deprogramming above.)  It doesn’t work for everyone.  Here, nature sometimes needs an assist from an oral surgeon who may be able actually to correct the anatomy of the joint itself.  This is always a last resort, and even most surgeons are not especially keen on performing this type of surgery.  This is frequently because the correction of the physical deformity does not usually halt the bruxing habits, and these may cause relapse of the surgery.

Arthroscopy


Patients who have disc displacement may benefit from arthroscopy. Arthroscopy is preformed in a surgical suite and only takes about one hour per joint. An arthroscope is placed into the joint in front of the ear. By arthroscopy, the surgeon is able to visualize the entire joint space and remove pathology. This often allows the meniscus to move more freely and function better.  There is very little postoperative discomfort and the patient is able to eat and drink immediately after the procedure.  This type of surgery generally involves reshaping bone and cartilage elements, and sometimes the complete removal of the meniscus.  Simple arthroscopies are relatively safe procedures.

Open surgical procedures

While arthroscopy is a procedure that requires two or three small incisions in order to allow the insertion of a fiber-optic instrument for visualizing the joint space, as well as small openings for instrumentation, open procedures require a complete incision to allow complete visualization of the joint.  The advantage to open procedures is that they allow the surgeon more room, so more complex replacement procedures can be accomplished.  This means that the surgeon can insert implants as well as remove and remodel joint components.

Meniscus and whole joint replacements

Joint implants and replacements have begun to come into their own in recent years.  These procedures are very expensive, and a good deal more risky than arthroscopy procedures, but if done by experienced, skilled surgeons, they may bring about relief when nothing else does.

The image below shows a panoramic x-ray of a patient of mine who had serious long term pain from deterioration of the TM Joints.  She had whole joint replacement surgery combined with surgery to correct a seriously underdeveloped lower jaw.   The surgery involved removal of both condyles (the ball of the joint) as well as both fossas (the sockets) and their replacement with titanium implants.  See the diagram above to get your bearings.  Titanium is a metal which allows for osseous integration (bone will actually attach to it naturally).  The surgery did relieve the patients pain on opening and closing the jaw, but was not without its negative after effects, as there was residual neuralgia (nerve hypersensitivity) which must be treated separately.  Click the image below to see larger images of this film, as well as before and after images of the patient herself.

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