Info for HealthCare Professionals

Head, neck and facial pain affects a significant percentage of the population (one in every four Americans) seeking care for both acute and chronic pain in the medical model we deal with everyday. The majority of temporomandibular disorder (TMD) sufferers are women, although men, young children and adolescence are also affected. Too often patients endure a frustrating and expensive doctor to doctor search to find answers for relief of symptoms.

These patients may seek Help first from you, their Primary Care Provider.

Background

Pain is a “disease” entity affecting a significant portion of the general public. It is estimated that 700 million man-days of work are lost each year as a result. It is further estimated that 500 million dollars is spent on the sale of non-prescription analgesics while another $1.2 billion is spent on prescription medications for the relief of pain.

Of this picture, head, facial and neck pain constitute a significant portion. When the time spent on the promotion of analgesics aimed at headache sufferer through the media is examined, the scope of the problem becomes apparent. Today it is widely recognized that a group of problems, “craniomandibular disorders,” are responsible for a significant portion of these symptoms.

Craniomandibular disorders are also responsible for a variety of ear symptoms including pain, ringing, buzzing, loss of auditory acuity and congestion. In addition, the suffer may experience pain or noises (clicking and/or grating) of the temporomandibular joint with movement as well as limitation of motion.

Symptoms

The most common symptom of TMD is noise in the joint, but it can also present without the joint noise. This noise is usually related to the rapid reduction of the fibrous disc malpositioned between the condylar head and the glenoid fossa. The sound is often accompanied by a restricted mandibular range of motion.

Pain is usually localized in the muscles of mastication, the accessory muscles of mastication in the posterior cervical area, the temporomandibular joint and the area about the ears. Many of these patients complain of:

• Chronic headaches
• Limited mandibular movements or locking open/closed
• TMJ sounds; clicking, popping, grating
• Dizziness
• Ear fullness or pain with no apparent other etiology
• Facial pain
• Neck pain or stiffness

Trauma, disease and developmental disorders can lead to internal derangement of the TM joint. This occurs when the normal physiologic relationship of the condyle, disc and fossa have been altered and compromised. Discomfort in the jaw joint can be the results.

It is becoming clear that a dentist who is specially trained in treating these disorders, can best direct this care.

The nature of the problem

Craniomandibular disorders occur when the structural integrity of the TMJ and/or the physiologic orthopedic relationship of the maxilla and mandible is not present. When this exists, stresses are produced within the stomatognathic system and pain and/or dysfunction frequently results. This may occur in the joint, supporting the ligaments and associated musculature.

Craniomandibular disorders, in their broadest view, are classified as intracapsular and extracapsular problems.

Intracapsular

Intrancapsular disorders are characterized by structural alterations of the temporomandibular joint, which interfere with form and function and frequently produce pain.

This includes:

Diseases:

These consist of such entities as degenerative osteoarthritis, rheumatoid arthritis and neoplasms.

Developmental Disorders: These problems occur as a result of abnormal development of the joint.

Injuries:

These occur when trauma is induced to the jaw, either by direct or indirect. Micro or macro trauma can be an etiologic factor (i.e. whiplash).

Internal Derangements:

These derangements occur when the physiologic relationships of the condyle, disc and fossa relationship have been lost. These comprise the vast majority of problems. Because of the frequency of occurrence, this problem will be addressed in detail.

In the normal anatomy of the TMJ, seen in Figure 1, the three major components of the TMJ are identified. The articular fossa (A) is formed from a depression in the temporal bone of the skull. Articulating in this fossa is the mandibular condyle (B). The two of these form a type of “ball and socket” articulation. Interposed between these structures is a fibrous pad, the articular disc (C), Along with other functions, the disc acts as a “shock absorber” between the fossa and the condyle, keeping the bones from rubbing on each other and assuring a smooth functioning joint.

In a typical derangement, the disc assumes an abnormal position forward of the condyle due to the stretching or tearing of the discal attachment apparatus. It has been referred to as a “slipped disc” of the jaw.

When this is present, a click is heard during opening movements on the affected side(s) and is also frequently present during closing. The noise may be audible but frequently requires a stethoscopic auscultation or the use of sophisticated instrumentation such as doppler ultrasound or digital sonography. This condition is termed an “anterior disc displacement with reduction”.

In Figure 2 the functional mechanics of the problem are illustrated. In the closed position, the disc is located anterior of the condyle. At some point in the opening movement the slack in the discal attachment is taken up and the condyle slips under the disc with a pop or click being produced. On the closing movement, the disc again slips off the c
ondyle and a closing click is elicited. The closing click is frequently softer in its intensity and is more difficult to hear.

If this condition is left untreated, it may ultimately result in an “anterior disc displacement without reduction,” frequently referred to as a “closed lock.” In this condition, because of the trauma and constant abuse to the disc, alterations in form occur. The patient presents with limitation of motion because the disc does not reduce to its normal position during opening and acts as a mechanical obstruction with a “wedging action” being produced. This prevents normal translation of the condyle.

In both of these dsyfunctions, degenerative osteoarthritis is frequently the long term result. This may produce severe alterations in form and function.

Derangements of the temporomandibular joint may be painless but most often are accompanied by pain-often severe-in the head. This principally occurs in the temporal, periorbital and suboccipital regions. In addition, facial pain and neck pain are encountered. This pain may emanate from the joint itself (with or without referral to other areas of the head) or from muscle dysfunction such as spasm and myofascial trigger points.

Extracapsular disorders occur when the mandibular trajectory of closure from its acquired postural rest position is not coincident with physiologic TMJ/neuromuscular trajectory of closure.

When the condyles are properly positioned within the glenoid fossa with the articular disc in its proper relationship to these structures and the mandibular musculature functioning at its optimal length, a physiologic trajectory of movement through space to closure is produced. If, however, the dental occlusal relationship is not coincident with this trajectory, an accommodative trajectory- and therefore an adjusted postural rest position of the mandible- must be produced. This occurs as a result of proprioceptive input with resultant adjustment of position. In addition, to the adjusted postural rest position of the mandible in the sagittal and frontal plane, a decrease in the vertical rest position of the mandible is also frequently encountered, forcing the muscles to function at less than their optimal length.

As a result:

Improproper Occlusion of the Teeth: When teeth do not fit together properly, it causes sustained microtrauma to the joints. When this condition is prolonged, the body begins to compensate by involving muscles in other areas: the neck, throat and upper back.

Muscle Hyperactivity:

This goes hand-in hand with internal jaw joint problems. Any condition prevents the complex systems of muscles, bones and joints from working together in harmony can contribute to TMD. Various ways this system can be disrupted include trauma, connective tissue disorders, arthritis or skeletal malformation.

Posture:

Poor posture places unnecessary wear and tear on the joints including the jaw joints. Over time, consequences of postural neglect can be as damaging as an injury.

Stress:

Increased physical and emotional stress is another factor that impacts patients with TMD as it reduces the adaptive capabilities of the jaw. Some patients unconsciously brux and/or clench their teeth in response to increased stress. Chronic clenching and bruxing creates strain on the TM joints and muscles which can exacerbate TMD problems.

As a result of this adjusted postural position, the stomatognathic musculature and TMJ’s must exist in a “stressed” condition. With this condition present, joint pain as well as muscle dysfunction (spasm and myofascial trigger points) are produced. This causes similar subjective symptoms as those encountered with intracapsular problems, with the exception of joint noises. A representation is seen in Figure 3

Associated Symptoms

Up to this point, primary emphasis has been on the various head and facial pain symptoms encountered with craniomandibular disorders. It must be recognized, however, that a strong and direct biochemical relationship exists between all the muscles of the head and neck. As a result of reciprocal muscle function, dysfunction and pain in the stomatognathic muscles frequently results in dysfunction and pain in the cervical muscles, with resultant neck pain. This may ultimately involve the entire upper quarter. Also, because of the diverse distribution of the trigeminal nerve, nociceptive input in one area may ultimately produce pain anywhere along that division.

In addition, because of the strong relationship of the stomatognathic and otologic systems from both an embryologic as well neurologic and functional perspective, ear symptoms are frequently found in craniomandibular disorders. These consist of congestion, pain, buzzing, ringing, loss of auditory acuity and equilibrium problems.

Etiology

The factors responsible for craniomandibular disorders may be single or multifactorial. Development factors responsible for a malrelationship of maxilla and mandible is a frequent finding. The symptoms may emerge during childhood or may not occur until adulthood after years of day to day trauma. Some cases may be iatrogenic in nature. For example, the loss of teeth without adequate replacement may cause a change in jaw position. In addition, direct trauma to the jaw can be a factor. It is also accepted that indirect trauma, such as whiplash type injuries, can produce TMJ disorder. It is known that a significant portion of cervical whiplash injuries have an accompanying mandibular whiplash. This type of trauma can produce stretching or tearing of the ligaments in the joint and also cause damage within supporting musculature.

Besides the obvious causes, there are cases where the exact etiology is difficult to determine.

What to do

If standard medical evaluation and diagnostic testing have failed to reveal a cause for the symptoms discussed here referral to a dentist specially trained in the diagnosis and treatment of craniomandibular disorders and orofacial pain should be considered. Many dentists do not treat or are not trained to treat these problems, however, and consequently a blanket referral of “see your dentist” may not be appropriate.

Summary

Head, facial, neck pain, jaw dysfunction, and ear symptoms and ear symptoms are common findings in the general population. Craniomandibular disorders are a frequent cause. Because of its common occurrence, it should always be included in the differential diagnosis in patients with these symptoms.

Differential Diagnosis

Our practice utilizes advanced computerized electronics to obtain necessary data such as accurately detecting jaw joint sounds with Joint Vibration Analysis. This provides a far greater degree of accuracy than the human eye or stethoscope can detect. We employ Spiral Tomographic Radiographic Scanning as well as other special radiographic studies.

Multidisciplinary Approach

Positive findings in these studies usually indicate that the dentist is the supporting provider to the referring health care professional. Working together with the patient’s physician or other health care professional brings effective team management to the patient to correct the problem.

Conservative Treatment

With many hours of special education, training, experience and modern diagnostic skills, we bring a great deal to the health care team addressing the special needs of the head, neck, “TMJ” or facial pain patient.

Once accurately diagnosed, conservative treatment methods, rather than surgery or drugs, are often the most successful for long-term pain relief. This results in the teeth, muscles, joints all working together in harmony. If a bad bite is determined to be a potentially contributing factor, usually custom-made orthotic (also known as a “splint”) is fit to stabilize the new postural position of the jaw and other skeletal elements.

Along with orthotic, adjunctive treatments that may be suggested (if necessary) include referrals to other professions and other modalities such as:

• Physical therapy
• Spray and stretch
• Massage therapy
• Trigger point injections
• Hot/cold therapy
• Stress counselingIontophoreses
• Nutrition counseling
• Chiropractic

When medical evaluation and tests have not revealed the “cause” of symptoms…

TMD Dentistry may be the answer for your patients.

Laser, dental procedures such as orthodontics or reconstruction may be required as more permanent forms of treatment.

Consult with us for undiagnosed head, neck, facial pain, whiplash injuries, jaw malposition or Tm joint arthritis. Dentistry brings a new approach to diagnosis and treatment along with providing objective, fully documented case reports.