TMD/OROFACIAL PAIN A PERSONAL NOTE
In my practice and as a director of a TMD – Facial Pain Clinic, I deal with people suffering from chronic pain- from moderate to unbearable pain. Often they have suffered and searched for answers for months or even years. Some have seen several physicians or dentists previously and have been treated for a variety of misdiagnosed ailments. They come asking:
- What is causing the pain?
- Is there something seriously wrong?
- How can I get relief?
- Will I ever feel pain free again?
- How drastic is the treatment to provide relief?
- How long will treatment be?
In order to answer their questions, allay fears, educate sufferers, and also their family, and friends, and assure you that there is hope for most people, I have written this section of the web site.
I hope it will help you to understand and overcome the fears surrounding TM Disorders.
Steven B. Syrop
TMD/OROFACIAL PAIN: DEFINITIONS
Many people ask do I Have TMJ? Or they ask what is the difference between TMJ and TMD? Let me try to explain what these terms are and how they are used.
TMJ stands for Temporomandibular Joint. It is the jaw joint located just in front of the ear. The temporal bone is located on the side of the head and the mandible is the lower jawbone. Where they meet is the temporomandibular joint (TMJ).
TMD stands for temporomandibular disorder. This term is more inclusive than TMJ; it refers to problems in the joint as well as problems of the muscles that are attached to the joint.
Most people have a combination of muscle and joint problems (TMD). However, the terms TMD and TMJ are many times used as catch phrases to include a variety of facial pain disorders.
TMD/OROFACIAL PAIN: SYMPTOMS
TMD Disorder sufferers experience a variety of symptoms- some so common that it seems almost everyone has experienced at least one of these at some time. Approximately in the order of prevalence here are typical symptoms.
- Pain when yawning, chewing or opening the mouth widely
- Clicking or popping sounds when the jaw is opened or closed.
- Sore or stiff jaw muscles
- Difficulty opening the mouth
- Locking or sticking of the jaw
- A change in the bite
- Pain in or around the ear or face from the jaw joint, or pain from the jaw muscles.
Some of these warrant a few words of additional explanation.
HEADACHE: Many medical conditions may result in headaches; a common cause is tension of the muscles, which close the jaw, especially the temporalis muscle. Headaches that do not respond to treatment need further evaluation by a neurologist.
CLICKING POPPING AND OTHER JAW JOINT NOISES: Often people will hear noises from their jaw joints. A normal healthy joint does not make any noise. However, people have jaw joints, which produce sounds, and they do not develop any problems. When jaw sounds are accompanied by pain and dysfunction it is more significant.
TMD/OROFACIAL PAIN: ANATOMY
THE BONES: There are two movable joints in the face; the right and left temporomandibular joints. (TM joint or jaw joint). The TM joint is formed by two bones; the temporal bone and the mandible. It is located in front of the ear. By placing your fingers in front of your ear and opening your mouth, you can feel the joint move. The part of the mandible that is in the joint, the condyle, glides along the surface of the temporal bone as the mouth opens. Between these two bones is an articular disc.
THE DISC: A film of fluid surrounds the articular disc, positioned between the bones of the joint. It cushions the forces between the bones allowing for smooth motion during opening and closing. If it is displaced it can cause clicking or jaw locking.
LIGAMENTS: The disc and mandible are attached to the skull by ligaments. If the ligament gets stretched out the disc becomes displaced. It was once thought that ligaments could not heal if damaged. We now know that the ligaments in this joint can heal very well. Under the right conditions the ligament can reorganize to produce a second disc to replace the damaged one.
MUSCLES: The muscles under the skin of the face are divided into two categories, supplied by two different nerves. The muscles responsible for jaw movement when we eat and talk are called muscles of mastication. The other group is called the muscles of facial expression which are responsible for showing our emotions, by smiling or raising our eyebrows. It is usually the muscles of mastication that are involved in producing the pain of TMD.
NERVES: The face, head and neck contain a multitude of nerves. Sensory nerves convey information about our environment, such as hot, cold pressure and pain. The motor nerves are connected to muscles. Stimulation of motor nerves causes muscles to contract.
The two most important nerves of the face are the trigeminal nerve, which is mostly sensory and the facial nerve, which is mostly motor. The trigeminal nerve goes to the teeth. The facial nerve controls the muscles of facial expression. It is usually the trigeminal nerve that is involved in orofacial pain.
TMD/OROFACIAL PAIN: CAUSES OF TMD
INJURY: A severe injury to the jaw can result in a fractured jawbone. If the force of a blow to the jaw is transmitted to the TM joint it may cause bleeding or inflammation in the joint. It may disrupt the disc causing locking and pain.
Other causes of TMD are not as clear.
GRINDING AND JAW CLECHING (Bruxing): Tooth grinding and jaw clenching are two very common oral habits which involve increased activity of the jaw muscles and may add stress to the TM joint. Many people grind and clench without symptoms. However, some people who clench or grind while sleeping may complain of sore jaw muscles upon waking in the morning.
STRESS: Thousands of years of evolution have prepared our bodies for only two responses to stress: fight or flight. In our society these options are not usually possible. We must deal with the reality of the situation, which means internalizing our stress. The response to stress is complex involving many biochemical and physical changes. Stress may increase muscle activity such as grinding or jaw clenching.
DEPRESSION: Depression magnifies our perception of pain. The brain chemicals involved in causing depression elevate our perception of pain. People who are suffering in pain for over six months may start to exhibit signs of depression.
JAW POSITION AND BITE: Where your jaw should be positioned and how your teeth fit together is a very controversial topic. Some people feel a bad bite causes TMD. Recent research suggests that there is very little relationship between the bite and developing TMD.
TMD/OROFACIAL PAIN : DIAGNOSIS
No treatment should begin until a proper diagnosis has been established. There are three common diagnoses:
MYALGIA- MUSCLE PAIN: Another term for this is Myofascial pain. It involves the muscles that move the jaw, and may extend to the neck and shoulder muscles. This is the most common category of TMD.
INTERNAL DERANGEMENT: The disc in the TM joint is out of position. This may cause clicking or locking. Associated with this may be synovitis or inflammation of the joint.
ARTHRITIS: The most common form of arthritis is osteoarthritis or sometimes referred to as “wear and tear” arthritis. This is caused by a loss of cushioning of the joint. Less common than osteoarthirits is rheumatoid arthritis. This is a systemic autoimmune disease that can affect many joints.
In order to “see” into the TM joint several types of images are available, to assist making a diagnosis.
PANORAMIC X –RAY: This shows the basic bone structure.
C-T SCAN: This is a computer assisted x-ray which is very accurate in viewing the bones.
MRI: This is the gold standard for visualizing the disc and can also show fluid in the joint.
BONE SCAN: This test can show bones that are actively growing.
TMD/OROFACIAL PAIN: TREATMENT
There are many types of treatment available for TMD and facial pain, falling into two broad categories.
- Conservative Treatment: These are reversible forms of treatment such as exercise, medications, physical therapy, and bite appliances.
- Non-Reversible Treatment: These treatments are invasive and can not be reversed such as grinding teeth down, capping teeth, and open joint surgery.
INITIAL CONSERVATIVE TREATMENT: The good news is that most TMD problems respond well to conservative, reversible treatment. Simple home care consisting of massage and jaw stretching exercises, adhering to a soft food diet, and avoiding damaging habits such as tooth clenching bring relief to many people. The use of medications and oral appliances are also helpful in alleviating TMD symptoms. It is almost always recommended that patients start with conservative care and if that is not sufficient then consider more invasive treatments.
Since oral appliances are commonly prescribed, additional information is warranted. Oral appliances have various names: bite plates, night guards, splints, and orthotics , to name a few. They all refer to the same thing. A bite plate is made of acrylic, which covers either, the upper or lower teeth. It snaps over the teeth and is easily removed for cleaning. It helps to relax the jaw muscles; it reduces pressure on the jaw joint, and protects the natural teeth from being worn down. Not all bite plates are designed the same way. If used improperly a bite plate can alter the bite unintentionally. If designed correctly and not worn 24 hours a day it should not alter the bite.
SURGERY: If conservative treatments are not effective and there is something in the TM joint to fix then surgery may be appropriate. The benefits and risks of surgery must be fully discussed with the surgeon prior to any decision. Surgery when appropriately indicated has benefited many patients. There are two types of surgery available:
Arthroscopic Surgery: This is minimally invasive surgery. A fiber optic needle is inserted into the joint, the damage can be visualized and through a second needle very small instruments are utilized to make surgical repairs, deposit medications very accurately, and flush out and clean the joint. The risk level of this procedure is low and the recuperations time is fast.
Open Joint Surgery: There are certain times when it is necessary to open the joint surgically to repair the damage. Although more invasive than arthroscopy, more definitive repair is possible with open joint surgery however, the healing time is longer.
TMD/OROFACIAL PAIN: HOPEFUL OUTLOOK
Realize that the rush to invasive treatments is not necessary. For most people reversible treatments such as jaw exercises, medications, bite plates, and awareness of habits will be effective tools to alleviate pain. The proper diagnosis combined with simple conservative care enables us to help TMD/ Orofacial pain sufferers to manage the pain and resume healthy, normal lives.
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