Treatment Options
The acronym “TMJ” is a broad, umbrella term that covers a wide range of disorders. “TMJ” is not a specific, well defined condition that is the same for every patient. TMJ-related problems can vary from fairly simple, straightforward conditions to conditions that are quite complex.
Confusion about this can arise because the symptoms, in all of these variations, can be fairly similar, although the severity of the symptoms may vary. Therefore, distinctly different TMJ-related conditions are often grouped together because of the similarity of their symptoms.
However, the symptoms are not the disorder. In each variation, the symptoms are an expression of the actual disorder. Treatment, whatever it may be, should address the underlying disorder that is producing the symptoms. If only symptomatic treatment is proviced, the patient is likely to be left predisposed to have the symptoms return in the future.
There is no single, universal treatment that is appropriate for all of these variations. Treatment of a temporomandibular disorder should always be based on a biologically-specific diagnosis; i.e. a recognition of the actual anatomic and physiologic basis for the disorder. Arriving at a specific diagnosis requires completing a thorough history and a thorough exam. Only after taking the history and doing the exam can the treating individual accurately categorize the underlying condition, and therefore know what treatment is appropriate for that specific condition.
The treating clinician should be able to describe to the patient the nature of their problem and explain the treatment objectives that will hopefully resolve the actual condition, not just the symptoms.
If a biologically-specific diagnosis cannot be defined and described to the patient, it may indicate that the clinician has only a limited understanding of the nature of the specific disorder. This may also indicate that any proposed treatment is intended to do no more than address the symptoms, not the cause.
A patient should not be reluctant to ask the clinician if the proposed treatment addresses the condition that is producing the symptoms. If the patient feels uncomfortable with the response to this question, they should continue to seek help for their condition by a clinician with a more in-depth understanding of their problem.
Described below are several examples of overlapping conditions that may have no distinct demarcations of signs and symptoms.
1. Facial Pain with No History of Sounds (clicking/popping) from the Jaw Joints (TMJs)
The symptom of facial pain, alone, is not sufficient to make a biologically-specific diagnosis. To arrive at a diagnosis requires taking a thorough history and examination. A knowledgeable clinician should, on the basis of this information, be able to determine a biologically-specific diagnosis; i.e. be able to describe the source and cause of the pain.
2. Jaw Joint (TMJ) Sounds with No Pain or Limited Opening
Sounds such a clicking and popping from the jaw joints (TMJs) are common in the general population. Several studies done in various countries have generally agreed that with examination, alone, 30-40% of the general population demonstrate these sounds. Most of these individuals seem to go through life without any adverse result.
However, for a small portion of this group, problems can develop, including pain and other “dysfunction” of the jaw joints. There is currently no means of identifying which of these individuals who have clicking or popping will develop further problems.
However, if the popping becomes louder or more frequent, or if catching of the joint is noticed, it is advisable for the individual to seek knowledgeable help as soon as possible. The same would be true if pain develops associated with these sounds or if the popping stops and there is then a limited ability to open the mouth all the way.
There are a limited number of dentists who have sufficient knowledge and experience to provide good advice and definitive treatment, when that is indicated. A dentist whose practice is primarily focused on the treatment of TMJ related conditions is usually the best choice.
3. Recent Onset of Jaw Joint (TMJ) Click/Pop with Associated Facial Pain
This would be an indication that a thorough history and examination should be done soon to determine exactly the nature of the condition that is producing the pain. Based on the information gathered from the history and examination, a knowledgeable dentist with experience treating these condition should be able to clearly describe the condition that is producing the pain and treatment that would be appropriate.
The history and exam should determine whether the pain is entirely from muscles or whether there is pain also coming from the jaw joints (TMJs). Muscle pain can occur for a variety of reasons. When there is pain coming from the joints, some of the muscle pain is likely to be a result of tightening of the muscles in an attempt to protect the joint from painful movement. Treatment should be directed at the underlying source of the pain, not simply at reducing the symptoms.
4. Prior TMJ Click/Pop That Has Now Progressed to Intermittent Catching or Locking
Whether or not there is pain associated with this condition, at the earliest sign of catching or intermittent locking of the jaw joint (TMJ) the patient should seek immediate help from a knowledgeable and experienced dentist. When catching and intermittent locking begins, there is an increased potential for this to progress to persistent locking of the joint. If locking of the joint should occur, effective treatment becomes more difficult, less predictable, and often more costly.
5. Persistent Limited Opening, Facial Pain, Prior History of TMJ, Prior Click/Pop Now Absent
If clicking or popping of the jaw stops, very often there will be a noticeable change in the ability to open the mouth compared to when the jaw was still popping. What has happened is that the jaw joint has “locked”. This does not mean that the locking completely prevents mouth opening, but that the ability of the locked joint to move has been restricted.
If there is pain accompanying the locking, initial treatment should first be focused on relief of symptoms. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, oral appliance, sometime called a “splint”.
However, this alone will seldom cause the joint to spontaneously unlock. Often physical therapy, in combination with wearing the oral appliance, will facilitate a reduction in symptoms and can occasionally cause the joint to unlock if undertaken soon enough. The window of time when a locked joint might unlock is very limited. Immediate attempts to unlock it is the best hope for doing so.
In more severe instances of locking, TMJ surgery may be appropriate. However, it is usually best to attempt to manage the problem by non-surgical means prior to consideration of surgery.
Surgeons who do TMJ surgery typically do not provide non-surgical treatment. The dentist who provides the non-surgical treatment should coordinate additional care with the surgeon who will do the TMJ surgery.
6. Long-Standing Limited Opening with Facial Pain & Grating/Grinding Sounds from TMJs
Patients with a longstanding limited ability to fully open their mouth may have, at some point in the past, had one of their jaw joints lock. It is not uncommon for jaw locking to occur without pain. In such cases the patient may have initially simply accommodated to this limited opening.
However, at some point in time, pain and/or grating/grinding sounds may develop in the locked joint. The grating/grinding sounds are indicative of a breakdown of the tissues within the joint and may not necessarily lead to immediate pain. Pain can develop long after the original locking of the joint and may result from some triggering mechanism, such as trauma to the weakened and predisposed jaw joint (TMJ).
Appropriate treatment for this condition should first be focused on management of the pain. This will involve addressing unfavorable loading of the locked joint, which will also improve the potential for adaptation of the tissues within the joint. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, oral appliance. Often physical therapy, in combination with the oral appliance, will facilitate a reduction in symptoms. This approach will frequently be an effective means of managing the symptoms.
If non-surgical treatment with an oral appliance and physical therapy proves inadequate to reduce symptoms and improve function, this may be the appropriate time to consider a surgical consultation. The dentist who provides the non-surgical treatment should coordinate additional care with a surgeon who would do the TMJ surgery.
7. Age-Related Onset of Grating/Grinding Sounds from TMJs
Grating/grinding sounds from the jaw joint (TMJ) is usually indicative of a breakdown of the tissues within the joint. This breakdown of tissues may not necessarily lead to pain. Not uncommonly this type of progressive change may lead to a shortening of the joint, which can cause a change in the bite.
When this occurs in an older person, particularly if there is no limitation of opening, it is usually best to initially do nothing other than manage any symptoms that may be present. Treatment will primarily involve addressing loading of the joint. This will also improve the potential for adaptation of the tissues within the joint. The most effective means of doing this is with the use of an appropriately designed, and appropriately adjusted, oral appliance. Often physical therapy, in combination with the oral appliance, will facilitate a reduction in symptoms and improvement in function.
As mentioned above, when there has been significant breakdown of the bony parts of the joint, a change in the patient’s bite can occur. This breakdown may occur slowly and may not be recognized by the patient until a significant change has occurred. It may seem that this change has occurred suddenly when, in fact, it more likely has progressed slowly. Such a change in the bite should initially be managed by the use of the oral appliance, and, in an older person, this may be adequate as a long-term basis, perhaps even having them continue wearing it on a limited basis, such as during sleep.
However, although fairly uncommon, this type of change can also occur in a somewhat younger patient. In such cases, there may be reasons to consider making permanent dental alteration in the bite. If this is to be considered, it is always advisable to be reasonably certain that the changes within the joint, which have led to this bite change, are not progressing.
When the need for a more permanent bite correction is anticipated, it is usually advisable to obtain quality imaging of the joints early in treatment, to be used as a baseline representation of the affected joint at that point in time. Later, when the symptoms have resolved and sufficient time has passed to allow for “healing” of the affected joint, comparing the initial imaging with a second imaging study will provide evidence as to whether the degenerative changes within the joint have stabilized. Only if there is a clear indication that the degenerative changes have “healed” should any permanent dental correction of the bite be undertaken.
8. TMJ Sounds & Facial Pain in a Patient with Chronic Tooth Grinding (Bruxism)
Before any treatment is undertaken to treat either the pain or the tooth grinding, a thorough history and examination should be done to determine exactly the nature of the condition that is producing the pain; i.e. a biologically-specific diagnosis, not just “TMJ”. Based on the information gathered from the history and examination, a knowledgeable dentist, with experience treating these conditions, should be able to clearly describe the condition that is producing the pain. Then an appropriate course of treatment can be recommended. Certain conditions, such as sleep disorders, can contribute to tooth grinding during sleep. And certain medication are known to cause individuals to grind their teeth more. These factors need to be taken into consideration in making treatment choices.
One of the most important things that should come from the history and exam is whether the pain is entirely from muscles or whether there is pain also coming from the jaw joints (TMJs). Muscle pain usually results from excessive, prolonged contraction of the muscles. There are a variety of things that can contribute to this excessive muscle activity, including bruxism.
One of these is pain that is coming from other sources, such as joint pain. When there is pain coming from the jaw joints, some of the muscle pain is likely to be a result of tightening of the jaw muscles in an attempt to protect to the joint from painful movement.
Jaw joints that are healthy and structurally intact can be loaded during normal function without any pain. Pain that is coming from the jaw joints is typically the result of loading of tissues that are not able to tolerate frequent or prolonged loading, such as would occur with clenching or grinding of the teeth.
Clenching and/or grinding of the teeth is one of several contributors to excessive muscle activity that can lead to muscle pain. In a patient who has both muscle pain and jaw joint pain, one of the objectives of treatment would be to manage the load on the jaw joints, as well as to minimize the activity of the muscles involved in clenching and grinding. This can be accomplished by the use of an appropriately designed oral appliance, which will require adjustment over time. Changes on the appliance will occur, over time, secondary to altered muscle activity, changes in the TMJs, and wear on the appliance due to bruxism.
Treatment with an oral appliance will involve more than simply fitting it to the patient’s teeth and telling the patient to wear it when they sleep. Even the most effective occlusal appliances do not usually eliminate tooth clenching or grinding. But when properly designed and adjusted, an oral appliance can provide better support for the joint during sleep, manage the forces applied to the teeth and joints during bruxism, minimize wear and fracture of the teeth, and help create an awareness by the patient of bruxism activity.
9. Locking Open When Yawning or Other Wide Opening (Dental Visits)
Locking open of the jaw joints is an entirely different phenomenon than having the jaw lock closed. Locking closed has been described above. When the jaw locks open, it is referred to as “subluxation” or dislocation, meaning that the ball part of the joint (the condyle) moves too far forward during opening and gets “stuck”.
Usually this subluxation occurs in a person who has excessively limber or hypermobile joints. Such persons often know that they are more limber than other people or may have been called “double jointed”. They can often do things with their joints that the average person can’t do. This joint hypermobility is more common in females and is usually more pronounced in a younger person and tends to decrease with age.
If you have had your jaw “lock open”, you may have felt a bit panicked, not knowing what to do about it. A knowledgeable dentist should be able to instruct you in how to overcome this locking open. It usually is most easily accomplished by having another person do it for you.
Once locking open has occurred, it may happen more easily in the future. So the person whose jaw has locked open should be careful from that point forward to not open widely. When there is a need to yawn, it is a good idea to put your fist under your chin and prevent the jaw from opening as widely as it might have otherwise or to place the tip of the tongue against the roof of the mouth during the yawn.
10. Onset of TMJ Pain & Click/Pop During Orthodontic Treatment
Because clicking and popping occurs fairly commonly in the general population, the appearance of joint sounds alone may not be a reason for concern. However, if that clicking and popping has been accompanied by the onset of pain, this should be brought to the attention of your orthodontist and a proper evaluation of the nature of this condition should be done.
Carefully consider whether there might have been a triggering event that caused this change. For instance, trauma to the jaw or biting on something hard, etc. might have been a trigger. Having your mouth open for a prolonged time might be a trigger. You should also note whether the clicking and pain occurs fairly frequently or whether it occurs only at certain times or when associated with certain activities of the jaw, such as which side of your mouth you are chewing on when it occurs.
If this clicking and pain began following some change that was done to your braces, this may be an important clue. For instance, the use of elastics of a certain kind to activate tooth movement will sometime lead to a change of this kind. Any of these may be important and should immediately be brought to the attention of the orthodontist.
The significance of such a change may have different implications depending on whether you are fairly early in your orthodontic treatment or whether, perhaps, you are nearing completion.
Should the development of pain accompany the onset of jaw clicking/popping, there is sometimes a need to make changes in the orthodontic treatment plan However, your orthodontist will only be able to determine whether this is necessary if you report the onset of the joint sounds and pain as soon as you become aware of them.
11. In a Child Who Grinds Their Teeth, Jaw Soreness on Awakening
It should be appreciated that grinding of the teeth (bruxism) is common in children. Unless there are significant symptoms associated with this, seldom is there an indication to provide treatment. Wear that occurs on the baby teeth, that will be lost when the permanent teeth come in, should be of little concern.
However, children who have persistent headaches, “ear” aches or jaw pain that have not responded to other attempts at treatment should be considered for treatment that will minimize the adverse effects of tooth grinding. The most effective treatment is likely to be a removable appliance that fits over the teeth. However, because of the continuing growth and development of the child’s mouth and the loss of baby teeth and eruption of permanent teeth, it may be necessary to make a new appliance perhaps as often as every 6 – 10 months.
It is known that certain drugs used in the treatment of attention deficit disorder (ADD/ADHD) and autism spectrum disorders may have a side effect of increased bruxism.
12. Arthritic Changes in the TMJs of a Child
Most TMJ arthritic changes that are seen in children are related to a systemic inflammatory disease process. The most common is idiopathic arthritis, commonly known as juvenile rheumatoid arthritis (JRA). Typically both jaw joints are involved and may result in an altered growth pattern of the mandible, resulting in characteristic occlusal changes including an anterior open bite.
Trauma-induced arthritis in children more typically occurs on only one side and the impact on the dental occlusion is less noticeable immediately. However, it may lead to asymmetric growth patterns. Sophisticated imaging can differentiate these conditions.
