What are temporomandibular disorders (TMD), and what are the approaches we use to treat them?

TMD most often originates as a neuromuscular problem, sometimes due to dislocation or injury, sometimes genetic discrepancies, and sometimes it can be linked to arthritis; most often it is associated with stress. Symptoms include pain in and around the ear, chronic headaches or pain in the neck, tenderness of the jaw, or a clicking or popping noise when you open your mouth or yawn. As long as TMD is limited to the muscles only, we have a fair chance of improving the problem and sometimes correcting it altogether. If the problem is not addressed and becomes a joint problem (intracapsular problem), it becomes very difficult to obtain a permanent solution even though we manage to improve the condition.

Almost everybody has some level of TMD, but some cases become truly painful and interfere with our normal way of living. For certain patients, simple exercises relieve the problem. Relaxation and stress control are very important, too, because this can reduce the symptoms tremendously. But some cases are more severe. People suffering from TMD may have many different symptoms such as jaw pain, headaches, muscle spasms, fractured or loose teeth, ringing in the ears, swallowing problems and inability to chew, bite or open their mouths, earaches and many other combinations of symptoms that make their day-to-day life less fulfilling. That is why it is essential to diagnose the problem correctly and treat it in an inclusive way.

Each case is different. That is why we create an individual comprehensive plan to address the causes of the problems, in order to manage pain and eventually restore the masticatory system to the best condition possible. The best solution is to seek help at the first sign of problems. This allows us to address the disease before it ends up being non-responsive to any treatment.

We may also refer you for additional support to a trusted colleague in a field such as chiropractic or physical therapy to address other possible neuromuscular problems contributing to this condition. Some cases benefit from counseling, others from pharmaceuticals such as muscle relaxers, NSAIDs, or even antipsychotics. Dentox (a form of Botox used in dentistry) is effective, given the right circumstances.

Dr. Gotun has extensive training, which he constantly updates, as well as thirty years of experience in this area. In fact, he is one of the best neuromuscular dentists in the field.

Types of TMJ Disorders.

It is important to note that while the term TM Disorders is named for the temporomandibular joints, only 20-25% of patients have a pure joint-related problem. The rest suffer from a combination of muscular, joint and nerve pains that fit into the following broad categories:

• Joint related (internal derangements of the TM joint)
• Muscle related (myofascial pain and trigger points)
• Neck related (craniocervical disorders)
• Orofacial Pains 
• Nerve related Orofacial Pains (neurogenic pain or neuralgias)
• Stress related Orofacial Pains (psychogenic and psychosocial pain disorders)
  
  
  
  

How we approach the treatment.

Dr. Gotun utilizes splint therapy, using different splints that serve specific purposes to address problems that manifest themselves due to the way the teeth come in contact with each other. There are many possible causes of such imbalances, and some of them can be partly or completely corrected. To do this, we use splint therapy of different levels. A splint is a highly accurate therapeutic plastic mouthguard specifically designed for you to restore a resting balance of the muscles in the masticatory system with the precision within 5/10,000“. The splint treatment often is followed by an equilibration (grinding of the surface of the teeth where needed to correct the imbalance) or by rebuilding the teeth with crowns, or both.

The different splints.

Diagnostic splint: This is a full arch maxillary (upper jaw) splint with an anterior ramp (front teeth resting on a 10° flat plane) balanced to approximate centric relation (joint seated in the desired location). The purpose of this splint is to test a person’s ability to use and benefit from a splint. The splint itself is produced by Dr. Gotun on models derived from your teeth by taking a set of alginate impressions. He also uses a tool called a face bow to relate the teeth to your joints. Finally, he takes a bite model using softened wax to accurately relate the upper and lower jaws. The models are mounted on a semi adjustable articulator (SAM 2). The result is a splint made of clear, thermally adapted plastic that snaps onto your upper teeth. The appliance is tolerated with no problems by most patients. The procedure takes two ½ hour appointments. The adaptation phase for each patient varies from no time to a week depending on each patient’s sensitivity level.

The fabrication of a diagnostic splint is preceded by:

a. General oral exam.
b. Limited TMD exam.

Night time splint: This is a full arch maxillary (upper jaw) splint with a full arch ramp (all posterior teeth resting on a plane with equal contact on each individual tooth) balanced to approximate centric relation (joint seated in the desired location). The splint itself is produced by Dr. Gotun’s laboratory affiliate on models derived from your teeth by taking a set of alginate impressions. He also uses a tool called a face bow to relate the teeth to your joints. Finally he takes a bite model using softened wax to accurately relate upper and lower jaws. The models are mounted on a semi adjustable articulator (SAM 2) to produce the appliance of a heat cured, clear, very hard and durable material that snaps onto your upper teeth. The purpose of this splint is to allow a patient to rest comfortably at night as a result of the appliance’s ability to distribute clenching or grinding forces equally throughout the muscles of the masticatory system (generally speaking, the muscles of your face controlling the function of your jaw). The splint also eliminates the neurological feedback to your brain of the upper and lower teeth’s relationship to each other. This facilitates the initiation of a neuromuscular balance of the masticatory system and thereby limits the resulting discomfort of biting your teeth together subconsciously. The appliance is tolerated with no problems by most patients. The procedure takes three to four 1-2 hour appointments. The adaptation phase for each patient varies from no time to a week depending on each patient’s sensitivity level.

The fabrication of a night time splint is preceded by:

a. General oral exam
b. TMD exam
c. Cone Beam CT scan presently done by ImagDent using an iCAT radiographic volumetric scanner
d. Radiographic interpretation by a oromaxiofacial radiologist
e. The mouth needs to be free of pathology (cavities, gum disease and other pathology) to obtain a predictable outcome

Full time splint: This is a full arch maxillary (upper jaw) splint with a full arch ramp (all posterior teeth resting on a plane with equal contact on each individual tooth) balanced to approximate centric relation (joint seated in the desired location) much like the night time splint. The splint itself is produced by Dr. Gotun on models derived from your teeth by taking a set of alginate impressions. He also uses a tool called a face bow to relate the teeth to your joints. Finally, he takes a bite model using softened wax to accurately relate upper and lower jaws. The models are mounted on a semi-adjustable articulator (SAM 2). The result is a splint made of clear, thermally adapted plastic that snaps onto your upper teeth. The purpose of this splint is to allow a patient to rest comfortably 24 hours a day as a result of the appliance’s ability to distribute clinching or grinding forces equally throughout the muscles of the masticatory system (generally the muscles of your face controlling the function of your jaw). The splint also eliminates the neurological feedback to your brain of the upper and lower teeth’s relationship to each other. This facilitates the initiation of a neuromuscular balance of the masticatory system and thereby limiting the resulting discomfort of biting your teeth together subconsciously. The appliance is tolerated with no problems by most patients. It is worn 24-7 and the teeth are not allowed to touch during the whole course of splint therapy without the splint in place. The duration of treatment is 6 weeks to 6 months. There is an adjustment and measurement appointment about once a week during the total treatment. The end result is a repositioning of the jaw to a functional and comfortable position that is followed by whatever treatment is necessary to maintain this relationship indefinitely. The initial fabrication of this splint is the same as the night time splint. The subsequent appointments last anywhere from 15 to 30 minutes. The adaptation phase for each patient varies from no time to a week depending on each patient’s sensitivity level. After a stable position is obtained and pain, popping and crepitation symptoms are at an acceptable level, final treatment is planned after a pantographic analysis (a 100% duplication of jaw function onto a fully adjustable articulator) is performed. This could include any of the following treatments or a combination:

a. Equilibration (adjustments of teeth by grinding on the biting surface of the teeth)
b. Crowning of teeth
c. Braces
d. Orthognatic surgery (surgical approximation of upper and lower jaws)
e. Joint surgery

Other approaches to TMD therapy.

Injection therapy: As long as we are dealing with muscle malfunction, several forms of injection therapy can be utilized.

a. Steroid injection: Overworked muscles often develop “trigger points”. These especially sore areas of the muscle feel like hard ball-shaped spots in the tissue that can be very tender to touch. By first numbing these spots and then injecting them with a steroid solution, it is possible to reduce the inflammation. In addition, through exercise and relaxation, sometime also using a variation of cold and heat packs, the initial “bump in the road” can be improved. A follow up with night time splints and eventual permanent bite corrections can render drastic improvement.

b. Dentox (Botox A) injection: The level of activity of specific muscles can temporarily be reduced by using Dentox judicially. A thorough exam as for a full time splint is imperative. Misuse of this drug can temporarily cause undesired side-effects, such as reduced chewing ability and facial asymmetries. Dentox lasts for 4-6 months and the drug is very effective given in the right circumstances. The treatment needs to be repeated every 6 months to keep the TMD problem under control. It is a pain management strategy, but it does not solve the underlying problem of stress and tooth/jaw malalignment.

Physical therapy / chiropractic manipulation: A component of TMD problems that is related to bad posture and normal wear and tear relating to physical activity of different levels. Granted, people with a lot of accidents are more prone to residual problems than most. Any accident that can be described as a sudden impact relating to an accident or a sports related injury certainly can be contributing to a life of muscle problems and joint malfunction. The possibilities are vast and the results often misdiagnosed. Thorough evaluations of postural problems by qualified professionals are very important and should never be overlooked. Dr. Gotun frequently involves other professionals to evaluate the general health of his patients. There is a wide variety of possible contributing factors and if ignored, the consequences can be devastating.

Drugs: We live in a society that enjoys an enormous amount of effective drugs to help us cope with undesirable physical and mental problems. One of the sad facts of life is that many of them are not curing the problems but rather limiting the perception of the seriousness and the extent of the disease by an individual and thereby contributing to escalation of the problem by dulling the symptoms. For example, we can walk on a broken leg if we are under the influence of pain medication strong enough to hide the actual pain and original damage. But in spite of that, we also can, under proper supervision, use drugs to speed up healing and recovery.

NSAIDs: Some of the best helpers if used over a short period of time are categorized in a group called the nonsteroidal anti-inflammatory drugs (NSAIDs). Some of these are Ibuprofen, Aspirin, Advil, Tylenol, Naprosyn
and many more.

NSAIDs can be broadly classified based on their chemical structure. NSAIDs within a group will tend to have similar characteristics and tolerability. There is little difference in clinical efficacy among the NSAIDs when used at equivalent doses. Rather, differences among compounds tended to be with regards to dosing regimens (related to the compound's elimination half-life), route of administration, and tolerability profile. Some more common examples are given below.

a. COX-2 inhibitors
b. Celecoxib (FDA alert [1])
c. Etoricoxib FDA withdrawn
d. Lumiracoxib TGA cancelled registration
e. Parecoxib FDA withdrawn
f. Rofecoxib (withdrawn from market [2])
g. Valdecoxib (withdrawn from market [3])
h. Sulphonanilides
i. Nimesulide (banned by several countries for the potential risk of hepatotoxicity)
j. Ibuprofen[4]
k. Naproxen
l. Diclofenac
m. Licofelone
n. Licofelone acts by inhibiting LOX (lipooxygenase) & COX (cyclooxygenase)and hence known as 5-LOX/COX inhibitor

To make a long story short: NSAIDs used for a short period of time to reduce inflammation and pain are a very useful tool, but used indefinitely, NSAIDs can cause all kinds of physical problems which might not show up immediately. Problems like upset digestive system and even cancer can develop in some circumstances. NSAIDs used in conjunction with the aforementioned therapies are known to drastically boost the healing speed.

Muscle relaxers: Muscle relaxers like Diazepam (Valium) are in a group of drugs called benzodiazepines. When treating TMD, a small dose of the drug is taken right before bed time. It helps people sleep and it drastically reduces muscle hyperactivity. Used over a short period of time, for instance 10 days, some of the stress inducing TMD can be managed and healing can begin, in particular if it is used in conjunction with some splint or injection therapy. Diazepam used over longer periods is habit-forming and loses its therapeutic effect. It should not be used unless it is prescribed and supervised by a licensed professional.

Pain medication: Drugs containing codeine or hydrocodone like Vicodin, Lorcet and the like are far from the treatment of choice. Generally the medication creates an altered perception of the pain and has no healing effect. These kinds of drugs should only be used in extreme cases where there is an overwhelming need to limit pain immediately for a short period of time.

Other alternatives: TMD has been a disease that has been around forever. People that complain about headaches often have a TMD component that is part of the trigger mechanism. Healthy living, good eating habits, reduction of stress and increase in exercise are important contributing factors to promote the healing. There are special relaxing exercises that can be helpful. Reestablishing good posture and awareness of how you sit and function in your day-to-day active life are a must. Also, studying your sleeping position and sleeping habits are part of finding out what can be improved to promote healing.

The good news is that no matter the mildness or severity of TMD conditions, there may be ways to approach the problem and achieve a positive result. If you suspect you have TMD, or have been given a diagnosis that you do, the sooner you make the decision to do something about it, the more likely you will be to achieve a favorable outcome. The keys to success are a comprehensive approach to treatment and full cooperation from the patient. The right combination of treatment options, addressing contributing factors, and changes in one’s lifestyle can do miracles for even the most seemingly hopeless conditions. Dr. Gotun is well known for his expertise in TMD treatments, and there is no doubt that choosing our practice to help you is a great first step. We have the knowledge, expertise and experience in helping cases like yours. We always welcome your questions at 512-329-5555.

We are ready to help you heal whenever you are ready, too.