1/3	Trigeminal Neuralgia, aka TicDouloreaux or TN and Temporomandibular Joint aka TMJ Updated 8-19-07 You are at Page 1 of 4 Section 1-25 Page 1 of 4 Section 1-25 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info.html ud 08/25/2009 03:04 PM -0500 Page 2 of 4 Section 26-50 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info2.html ud 08/25/2009 03:04 PM -0500 Page 3 of 4 Section 51-75 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info3.html ud 08/25/2009 03:04 PM -0500 You are at Page 4 of 4 Section 76-100 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info4.html ud 08/25/2009 03:04 PM -0500 Page 4 of 6 Section 76-100 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info4.html ud 08/25/2009 03:04 PM -0500 You are at Tim Guith's Page 5 of 6 Section 101-125 Opiods http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/tim-guith.html ud 08/25/2009 03:04 PM -0500 You are at Page 6 of 6 TMJ Sections 126 to 150 http://www.BrianNelsonConsulting.com\temporomandibular-joint-tmj\info-faq.html ud 08/25/2009 03:04 PM -0500	2/3
	Temporomandibular-Joint-TMJ info faq Frequently asked questions.TMJ disorder, a dysfunction of the temporomandibular joint (which connects the lower jaw to the skull) can cause a wide variety of painful symptoms."> jmt-tnioj Temporomandibular-Joint-TMJ info faq Frequently asked questions. Compendium Page FOR TMJ aka Temporomandibular-Joint Welcome to my compendium website about: TMJ or Temporomadibular Joint The important words found on this site include: Contact information for this Website: Brian Nelson Webpage Marketing Consultant 31 Gessner Rd. , Houston, TX 77024 713-467-3025 Fax 713-467-3192 Click: E-mail me You can find this site again by typing in the Google search engine the very unique word " 1tnoiJralubidnamropmeT " which is "TempormandibularJoint1 " backwards. Article Word Count MSW

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108 Temporomandibular-Joint-TMJ info faq Frequently asked questions.TMJ disorder, a dysfunction of the temporomandibular joint (which connects the lower jaw to the skull) can cause a wide variety of painful symptoms."> jmt-tnioj

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Hi,

I am putting together this page to centralize some of the data on the internet about Trigeminal Neuralgia aka tic douloreaux. I have TN or some related version and Temporomandibular-Joint-TMJ
I took 2nd MRI and a MRA on Sat. Aug. 28, 2004. The only positive item discovered during those expensive tests was a pinched nerve resting on the spinal column. Medically the report said. Moderate spondylosis and annular bulging are present form C3-4 thought C 6-7, most serve at C 3-4. A 45 minute EMG determined that that problem was of minor concern for a nerve in the leg.

After reading the information about Trigeminal Neuralgia from the web I have located something about a problem I have had since May 2004. Reading about TN was depressing but consoling in that I am not alone with these inside the head pains. They are not a figment of my imagination.

Trigeminal neuralgia is universally known as the most painful affliction know to medical practice. It is not fatal but the nature of it can be suicidal. If you or a loved one has something similar to this disease write something about it and send it to me. If you want I can publish it on this website. Please remind me to list your story. My first visit to a neurologist Dr. R. was in July 2004. A prescription for Flexerel was given. After a week I determined that it may be the source of a very itchy rash on the right side of my neck. I stopped taking the medication and the rash went a way. Then I was given Neurontin. 9-13-04 my dosage was increased to 1800 mgs of Neurontin. I didn't think the 1800 mg was doing me any good. On 9-24-04 it was increased to 3000 mg (5 600 mg pills / day.) It It did not seem to be doing any good. I still received significant jolts to the left side of my face.

I had appointment with Dr. R is Oct 6, 2004. As usual I had to wait an hour and then I finally had to leave for another commitment without seeing Dr . R I had been treated by Dr. .R since July and my pain had not seem to be diminished. I located a specialist Dr. K Oct. 20, 2004. I was then put on 600 mg of Neurontin and 600 mg of Tegretol. It has significantly reduced my electrical jabs. October 28 I had a dental appointment for a routine cleaning. I mentioned my TN problems as my jaw ached considerably. I could not open my mouth easily for the hygienist to easily work on my teeth. Dentist Dr. TR suggested I considered us of a TNI device to prevent Bruxism, ie teeth grinding. It may be the cause of my very aching jaw pain which destroy my will to focus very long on anything. The thousands of electrical jabs in the middle of the night may have overworked those poor jaws causing me to tighten down on my teeth. I purchased the TNI. You can see a 6 minute video on it at www.HeadachePrevention.com I think that the low jaw seems to be much more relaxed and I can open my mouth further. The back part of the jaw still has aching pain which may be from getting used to the TNI device.

Based on my pain circulating from the top of the left side of my head to the deep part of my throat Dr. K thinks I have Atypical Facial Pain, ATFP .What is ATFP?. It is is a syndrome encompassing a wide group of facial pain problems. The outlook seems even worse than Trigeminal Neuralgia as some experts say that surgery is not usually a successful option for ATFP. It is usually treated with medication. Darn! You will find details about ATFP on website no. 4 of this compendium.

At the TNA Conference in Florida Nov 10-14, 2005 Often Dr. J said that this often means that there is more than one blood vessel compressing more than one nerve if you are skilled in looking for it.. All should be corrected during the same time if one chooses an MVD procedure. I have heard other MVD neurosurgeon Dr. K. state that he has never seen more than one blood vessel causing a problem. Now who do you believe.

My wife Rosemary and I attended the TNA National Conference on Trigeminal Neuralgia November 11-14, 2004 at the Walt Disney World Orlando Hilton in Florida. It consisted of some long days listening to the informative presentations provided by about 50 doctors. Enroute I discovered how true the information I had read how altitude change on an airplane can bring on more TN problems. Pain enroute was excruciating in the pressurized cabin. Also while I was at the conference I developed a full body rash.

On my return trip I increased my Tegretol dosage the day before and the day of travel as advised at the conference. It decreased the head pressure and increased my traveling comfort. Enroute hearing on my left side went out at the same time the altitude was affecting my TN pain. My hearing resumed after a nights sleep but 2 days later went out again prior to the return flight and did not return to normal in about 30 days.. I visited a ENT specialist DR. V who determined that my pressure was not correct in my left ear and was affecting my hearing. Holding my nose and blowing heavily with a closed mouth did not discharge the liquid in the ear area. DR. V did a lancing procedure which restored my left ear hearing.

November 12, 2004 I noticed the development.of a body rash . On Nov. 16, 2004 I reported the full blown body rash t to Dr. K. His immediate response was to immediately get off the Tegretol and up the Neurontin to cover this loss. When the rash disappeared a new drug Amytriptyline was prescribed starting with 10mg and increased to 30 mg. The Neurontin was up to 1200 mg/day.

About Jan. 7, 2005 while flossing my teeth I discovered that my top teeth would not line up with my bottom teeth. A dental visit on Jan. 11, 2005 with Dr. TR determined that there is a good chance that I have TMJ (Temporomandibular Joint Disorder) . Yuk. More pain and expense. Phone calls to my insurance company and a TMJ specialist office determined that it is not very likely that TMJ would be covered by insurance. If you have any experience with TMJ please let me know.

Also if you have any experience with anything about TN please contact me. If you find a web page with valuable information please send it to me and I will link to it from this website. You can find this site again by typing the word "neuralgia" in backwards "aiglaruen" in Google. the next TNA conference on TN will be in November 2006. If you have Trigeminal Neuralgia I would highly recommend that you and your spouse attend. You will meet many others with your similar problem and will hear many Doctors speak about the latest research and treatment in TN.

Brian Nelson

bnelson@PartyTentCity.com

31 Gessner Rd. Houston, TX 713-467-3025, Fax. 713-467-3192

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Temporomandibular-Joint-TMJ info faq Frequently asked questions. Compendium Page FOR TMJ aka Temporomandibular-Joint

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Scan down to Read about TMJ. Call me if I can help you. 713-467-3025 Brian

Trigeminal Neuralgia , TN, tic douloreaux, is the trigeminal nerve producing false signals from the brain sending excruciating lightening strikes of facial pain to one side of the face. Treatment is by medication, radiosurgery, craniofacial surgery or neurosurgery or Microvascular Decompression (MVD) for nerve pain relief. Trigeminal Neuralgia typically is near the nose lips, eyes, or ears.

Page 1 of 5.

by Brian Nelson
bnelson@PartyTentCity.com
713-467-3025 Houston, TX

Hi Aiglaruen

101 Started 8-25-04 Updated 8-19-07

Brian Nelson
www.BrianNelsonConsulting.com

31 Gessner Rd.
Houston, TX 77024
713-467-3025,
bnelson@PartyTentCity.com

Brian Nelson’s Report Pain on Left side of Head.
Document Initiated on 8-22-04 Last update 8-30-04 620am ..

Brian Nelson, 31 Gessner Rd. , Houston, TX 77024
bnelson@PartyTentCity.com , 713-467-3025 .

This letter is for the record and to keep a PAIN JOURNAL of where the above stated title problem stands.

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You are at Page 6 of 6 TMJ Sections 126 to 150 http://www.BrianNelsonConsulting.com\temporomandibular-joint-tmj\info-faq.html ud 08/25/2009 03:04 PM -0500

Slide down for detailed information about TMJ on this page.

Directory for TN websites

Brian Nelson's Introduction Page 1 of 4 Section 1-25 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info.html	25. Page 2 of 4 Section 26-50 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info2.html
1b The Directory	25. TNA Support Groups
2 Drug Awareness Articles	26t. TNA Patient Representative
3 TN Compilation Research Please Help	27. Excerpt From Trigeminal Neuralgia Synonyms, Key Words, and Related Terms
4 Information about Neurontin Drug	28. Jennifer Clough, TN Patient Personal Story.
5. TN Trigeminal Nerve Diagram	29 . FAQ What is TN
6. Important Subject Words on this Site.	30. Question TN Starts after root canal?
7. A growing arsenal of ways to treat TN	29. Directory of Keywords for TN
8.	30. Articles From Medical Literature
9. Brian's Symptom Details. The Future on this Pain Management.	32. Trigeminal Neuralgia / Tic Douloureux
10. Neurontin News May 20, 2004	33. Acoustic Neuromas
11 Neurontin News June 7, 2004 "Pfizer Sued Again Over Improper Marketing of Neurontin"	34. Chiari I Malformation
12 Trigeminal Neuralgia Introduction	35. Orbital Tumors
13 Neurontin News May 20, 2004	36. Pituitary Tumors
14. Ratings for Neurontin	37. Skull Base Tumors
15. Tegretol, Tegretol-XR	38. Multidisciplinary Medical Team
16. Suicidal Class Action Lawsuit.	39. Trigeminal Neuralgia (Tic Douloureux) What Is It?
17. Brian Nelson Affiliates	40. National Association Contact Info
18. Neurontin Lawsuit News. March 11, 2004	41. Tic Douloureux Overview
19. Treating Tirgeminal Neuralgia	42. Tic Douloureux Symptoms
20. Neurontin Law Suit News June 1, 2004	43. Tic Douloureux Exams and Tests
21. Complementary and Alternative Treatments for TN	44. Tic Douloureux Treatment
22. Upper Cervical Chiropractic Care	45. Tic Douloureux Follow up
23. Alliance for Human Rearch Protection.ance for Human Research Protection	46. Medical Glossary
24. The History of TNA, The Trigeminal Neuralgia Association.	47. Doctor Forums
	48. Support Groups for TN
25. TNA Support Groups	49.
25. TNA Support Groups	50.Tic Douloureux - Trigeminal Nerve

The Directory Page 3 of 4 Section 51-75 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info3.html	76. The Directory Page 4 of 4 Section 76-100 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/faq-info4.html
51. TMA in The News	77. Cranial Nerves: Review Info
52. Kaufmann's Guide to Trigeminal Neuralgia	78. Trigeminal Neuralgia from Health Otz.
53. Gamma-Knife Radiosurgery	79. Trigeminal Neuralgia Vascular Compression Syndromes
54. Trigemenial Neuralgia Informative Websites	80. Ostenoecrosis of the Jaw
55. Trigeminal Neuralgia Symptons	81. NINDS Trigeminal Neuralgia
56. What is Trigeminal Neuralgia?	82. Report of the Trigeminal Neuralgia Association 2nd National Conference Nov. 11-15, 1998
57. Ronald Brisban's Guest Books 1997 - 2001	83. Bruxism Sore Jaws from Teeth Grinding and Overuse
58. Trigeminal Neuralgia Medications	84. Prevent Tooth Grinding
59. Trigeminal Neuralgia Statement Testimonials	85.Data being added weekly.
60. Brian Nelson Consulting Affiliated Websites	86. Atypical Facial Pain: Conditions Facial Neuralgia.
61. Trigeminal Neuralgia Statement Testimonials	87 More Aypical Facial Pain
62. Gamma Knife Surgery Video	88. Excerpt from typical Facial Pain
63.Trigeminal Neuralgia Overview	89. TMJ Site Connection.
64. Trigeminal Neuralgia - A Personal Narrative	90. What is the Myelin Sheath.
65. Trigeminal Neuralgia- Root Canal Report	91.
66. Trials & Treatments of Anesthesia Dolorosa	92.
67. Trigeminal Neuralgia- Microvascular Decompression Introduction	92.
68. Magnetic Rsonance Angiography (MRA)	93.
69. Types of Facial Pain	94.
70. Book "Striking Back" George Weigel and Ken Casey M.D.	95.
71. Facial Neuralgia Resources	96.
72. Glossopharyngeal Neuralgia and other Cranial Disorders	97.
73. Glossopharyngeal Neuralgia Overview	98.
74. Glossopharyngeal Neuralgia Review	99.
75. Glossopharyngeal Neuralgia Causes & Treatment	100.

Temporomandibular-Joint-TMJ info faq Frequently asked questions.

Brian Nelson's Introduction Page 5 of 6 Section 101-125 http://www.BrianNelsonConsulting.com/trigeminal-neuralgia-tn/tim-guith.html	Page 6 of 6 Section 126-150 http://www.BrianNelsonConsulting.com\temporomandibular-joint-tmj\info-faq.html This Page.
101b The Directory	125. Overview and Causes
102	126 Overview. Temporomandibular joint
103	127. Anterior Displacement of the Left Temporomandibular Joint (TMJ) - Medical Illustration
104	128. TMJ disorder, a dysfunction of the temporomandibular joint
105.	129 .Temporomandibular Joint (TMJ)
106.	130. Temporomandibular Joint (TMJ)
107.	131. What is temporomandibular joint syndrome?
108.	132. Temporomandibular Joint (TMJ) Syndrome Alternate Names : TMJ or TMD Pictures & Images
109.	133. TMJ disorders
114.	138. Health INformation Temporomandibular joint (TMJ) Syndrome.
115.	139. Temporomandibular Joint (TMJ) Syndrome
116.	140. Medications for Temporomandibular Joint (TMJ) Syndrome
117.	141. Research on Brian's Pain Management. What Is Trigeminal Neuralgia?

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126 Overview. Temporomandibular joint

Temporomandibular joint (TMJ) syndrome or TMJ joint disorders are medical problems related to the jaw joint. The TMJ connects the lower jaw to the skull (temporal bone) under your ear. Certain facial muscles control chewing. Problems in this area can cause head and neck pain, a jaw that is locked in position or difficult to open, problems biting, and popping sounds when you bite.

The TMJ is comprised of muscles, blood supplies, nerves, and bones. You have 2 TMJs, one on each side of your jaw.

Muscles involved in chewing (mastication) also open and close the mouth. The jawbone itself, controlled by the TMJ, has 2 movements: rotation or hinge action, which is opening and closing of the mouth, and gliding action, a movement that allows the mouth to open wider. The coordination of this action also allows you to talk, chew, and yawn.

If you place your fingers just in front of your ears and open your mouth, you can feel the joint and its movement. When you open your mouth, the rounded ends of the lower jaw (condyles) glide along the joint socket of the temporal bone. The condyles slide back to their original position when you close your mouth. To keep this motion smooth, a soft disc lies between the condyle and the temporal bone. This disc absorbs shock to the temporomandibular joint from chewing and other movements. Chewing creates a strong force. This disc distributes the forces of chewing throughout the joint space.

Causes.
TMJ can be caused by trauma, disease, wear due to aging, or habits.

Trauma: Trauma is divided to microtrauma and macrotrauma. Microtrauma is internal, such as bruxism (grinding the teeth) and clenching (jaw tightening). This continual hammering on the temporomandibular joint can change the alignment of the teeth. Muscle involvement causes inflammation of the membranes surrounding the joint. Teeth grinding (bruxism) and clenching are habits that may be diagnosed in people who complain of pain in the temporomandibular joint or have facial pain that includes the muscles involved in chewing (myofascial pain). Macrotrauma, such as a punch to the jaw or impact in an accident, can break the jawbone or damage the disc.

Bruxism: Teeth grinding as a habit can result in muscle spasm and inflammatory reactions, thus causing the initial pain. Changes in the normal stimuli or height of the teeth, misalignment of the teeth, and changes in the chewing muscles may cause temporomandibular joint changes. Generally, someone who has a habit of grinding his or her teeth will do so mostly during sleep. In some cases, the grinding may be so loud that it disturbs others.

Clenching: Someone who clenches continually bites on things while awake. This might be chewing gum, a pen or pencil, or fingernails. The constant pounding on the joint causes the pain. Stress is often blamed for tension in the jaw, leading to a clenched jaw.

Osteoarthritis: Like other joints in the body, the jaw joint is prone to have arthritic changes. These changes are sometimes caused by breakdown of the joint (degeneration) or normal aging. Degenerative joint disease causes a slow progressive loss of cartilage and formation of new bone at the surface of the joint. Cartilage destruction is a result of several mechanical and biological factors rather than a single entity. Its prevalence increases with repetitive microtrauma or macrotrauma, as well as with normal aging. Immunologic and inflammatory diseases contribute to the progress of the disease.

Rheumatoid arthritis: Rheumatoid arthritis causes inflammation. As it progresses, the disease can cause destruction of cartilage and erode bone, deforming joints. It is an autoimmune disease involving the antibody factor against immunoglobulin G (IgG). Chronic rheumatoid arthritis is a multisystem inflammatory disorder with a persistent symmetric joint involvement. Certain infectious diseases may be the cause of rheumatoid arthritis.

127

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Anterior Displacement of the Left Temporomandibular Joint (TMJ) - Medical Illustration

This medical exhibit depicts the anterior displacement of the temporomandibular joint, or TMJ, from the LEFT side. Two illustrations of a lateral (side) view of the skull show the mandible (jaw) open and closed, revealing the displacement of the TMJ meniscus. To the immediate right are two enlarged cut-away sections of the dysfunctional TMJ showing the area in more detail. Labeled structures include the pterygoid muscle, mandible, temporal bone, meniscus, condyle and joint capsule.

What is the Temporomandibular Joint (TMJ)?

The temporomandibular joint (TMJ) connects the lower jaw, called the mandible, to the temporal bone at the side of the head. If you place your fingers just in front of your ears and open your mouth, you can feel the joint on each side of your head. Because these joints are flexible, the jaw can move smoothly up and down and side to side, enabling us to talk, chew and yawn. Muscles attached to and surrounding the jaw joint control its position and movement.

When we open our mouths, the rounded ends of the lower jaw, called condyles, glide along the joint socket of the temporal bone. The condyles slide back to their original position when we close our mouths. To keep this motion smooth, a soft disc lies between the condyle and the temporal bone. This disc absorbs shocks to the TMJ from chewing and other movements.

Today, researchers generally agree that temporomandibular disorders (TMDs) fall into three main categories:

• myofascial pain, the most common form of TMD, which is discomfort or pain in the muscles that control jaw function and the neck and shoulder muscles;

• internal derangement of the joint, meaning a dislocated jaw or displaced disc, or injury to the condyle;

• degenerative joint disease, such as osteoarthritis or rheumatoid arthritis in the jaw joint.

A person may have one or more of these conditions at the same time.

Causes of TMD

Severe injury to the jaw or temporomandibular joint can cause TMD. A heavy blow, for example, can fracture the bones of the joint or damage the disc, disrupting the smooth motion of the jaw and causing pain or locking. Arthritis in the jaw joint may also result from injury. Other causes of TMD are less clear. Some suggest, for example, that a bad bite (malocclusion) can trigger TMD, but recent research disputes that view. Orthodontic treatment, such as braces and the use of headgear, has also been blamed for some forms of TMD, but studies now show that this is unlikely.

And there is no scientific proof that gum chewing causes clicking sounds in the jaw joint, or that jaw clicking leads to serious TMJ problems. In fact, jaw clicking is fairly common in the general population. If there are no other symptoms, such as pain or locking, jaw clicking usually does not need treatment.

Researchers believe that most people with clicking or popping in the jaw joint likely have a displaced disc -- the soft, shock-absorbing disc is not in a normal position. As long as the displaced disc causes no pain or problems with jaw movement, no treatment is needed.

Some experts suggest that stress, either mental or physical, may cause or aggravate TMD. People with TMD often clench or grind their teeth at night, which can tire the jaw muscles and lead to pain. It is not clear, however, whether stress is the cause of the clenching/grinding and subsequent jaw pain, or the result of dealing with chronic jaw pain or dysfunction. Scientists are exploring how behavioral, psychological and physical factors may combine to cause TMD.

Source: National Institute of Dental and Craniofacial Research

128 TMJ disorder, a dysfunction of the temporomandibular joint (which connects the lower jaw to the skull) can cause a wide variety of painful symptoms.

What is TMJ Syndrome? Temporomandibular joint (TMJ) syndrome, also called myofascial pain dysfunction, is a general term for a number of muscle, joint, and nerve symptoms that seem to be related to disturbance or disease in the temporomandibular joint. TMJ syndrome is a fairly common condition, perhaps because so many of the symptoms seem to be at least partly stress-related, and modern life is notably characterized by innumerable stressors.

What is the temporomandibular joint? The temporomandibular joint is the joint that connects the lower jaw (the mandible) to the skull.

What are the symptoms of TMJ syndrome? TMJ syndrome can produce a wide array of seemingly unrelated symptoms:
--jaw pain
--chronic generalized facial pain (either a sharp pain or a dull ache)
--headaches
--earaches
--a loud roaring in the ears
--clicking or popping sounds when the jaw is opened
--difficulty in opening and closing the jaw
--difficulty, discomfort, or pain when biting or chewing
--neck, shoulder, chest, and back pain
--toothache
--dizziness

How is TMJ syndrome diagnosed? TMJ syndrome is difficult to diagnose--not only because of its potentially large number of disparate symptoms, but also because any of those symptoms can be associated with other conditions. Before arriving at a diagnosis of TMJ syndrome, the doctor must first eliminate other conditions that could be producing the symptoms. A professional diagnosis is necessary, and often the individual will have to see both a doctor and a dentist for an accurate diagnosis.

What causes TMJ syndrome? No one really knows the cause of TMJ syndrome. In fact, there seem to be a number of possible underlying causes. Some cases may have their origin in the way the jaw is structured, especially if there is malocclusion. Under conditions of chronic stress, even a slight malformation in the jaw can lead to TMJ symptoms. Some cases may be caused by sudden injury to the joint--for example, fractures or dislocations, such as might occur if the jaw is forced to open too widely while dental procedures are performed. And some cases seem to be the result of degenerative or inflammatory joint diseases, such as arthritis.

Professionals who treat TMJ syndrome also suspect that some cases are caused by poor mouth habits, such as chewing on hard objects, resting the jaw on the hands for prolonged periods, or clenching the jaw and grinding the teeth (bruxism). Certain musical instruments, like the violin and the trumpet, are also implicated in some cases because they can stress the jaw by forcing it into unnatural positions for extended periods of time.

In most cases, chronic stress leading to chronic habitual muscle tension and even to muscle spasms seems to be a significant contributor to TMJ syndrome.

How can TMJ syndrome be treated? Most doctors and dentists recommend treatment approaches that target the symptoms, rather than more drastic approaches such as surgery. Treatment programs for TMJ syndrome depend on the nature of the underlying causes of the condition, but most include some sort of counseling and training in stress-reduction and relaxation techniques, to eliminate stress-related factors that so often contribute to the dysfunction. Biofeedback, meditation, yoga, hypnosis, and breathing exercises are among the techniques that have shown positive results. Non-steroidal anti-inflammatory drugs (NSAIDS) such as aspirin, acetaminophen, or ibuprofen are often recommended to relieve pain and to counteract inflammation of the temporomandibular joint.

Many people get relief from using hot compresses. For some, exercise programs can improve jaw alignment and functioning. Bite plates or other devices intended to realign the jaw are often used as well, but there is no consensus on their efficacy among those who treat

TMJ syndrome.

129

Temporomandibular Joint (TMJ)

Mandibular condyle
Articular disk
Superior joint cavity
Articular eminence
External ear

130 Temporomandibular Joint (TMJ)

The Temporomandibular Joints are the points of attachment of the lower jaw to the skull. They are the two joints, one on each side of the face, just in front of the ears. Ligaments, tendons, and muscles support the joints and are responsible for the various jaw movements. If you place your fingers on the sides of your face just in front of your ears, and open and close your mouth, you can feel the movements of the TMJ.
The TMJ is the joint formed by the temporal bone of the skull (Temporo) with the lower jaw or mandible (mandibular). These joints move each time we chew, talk or even swallow. The TMJ is a sliding joint and also a ball-and-socket joint. They are among the most complex joints in the human body. There are two different movements associated with jaw opening and closing. For about the first third of the opening range the movement is hinge-like, and in the last two thirds of the opening range the condylar head slides forward and down. Closing movement occurs in reverse order. The temporomandibular joint contains a piece of specialized disc, which is primarily made of cartilage that keeps the lower jawbone and skull from rubbing against each other, called the Articular Disk. It lies between the condylar head and the roof of the Joint. The disc being attached to a muscle (lateral pterigoid) moves with certain movements of the TMJ. The two bones of the TMJ are also held together by a series of ligaments.

What is the normal range of mouth opening?
Normally when you open your mouth as wide as you can you will be able to place the last three fingers of your hand (middle, ring and little finger) perpendicularly (with your thumb pointing to the ceiling) between your upper and lower front teeth, provided that you can do so without pain or strain. In general, two fingers or less, is a limited range of mouth opening.

How can a dislocated (locked) jaw be reduced into its normal position?
A helper should stand in front of the person, place the thumbs on the gums next to the lower back teeth, and press first down and then back on the outer surface of the teeth. The jaw should snap back into position. The helper needs to keep the thumbs away from the chewing surfaces because the jaws close with considerable force.
Recurrent, chronic dislocation of the mandibular condyle that is unsuccessfully controlled by conservative means can be corrected through a surgical procedure called eminectomy. The rationale is to promote spontaneous self-reduction of a dislocation or convert it to an acceptable subluxation. (see section on surgical treatment.)

What are the symptoms associated with TMJ disorders?
The causes of temporomandibular joint disorder are a combination of muscle tension and anatomic problems within the joints. Sometimes, there is a psychological component as well. These disorders are most common in women between ages 20 and 50.
PRIMARY SYMPTOMS
1. Pain in the joints associated with jaw movements.
2. Intermittent “locking” episodes. A "locking" episode can occur during opening or closing movement. The person experiences an interruption of jaw movement and cannot close his mouth. In order to do so he must jiggle or self manipulate the jaw to the correct position. This occurs due to the articular disk, which rides on top of the condylar-head getting stuck, preventing the condylar-head from moving into the correct position, resulting in the dislocation of the joint. Each time it happens, injury occurs to the tissues in the joint and also to the tissues controlling the articular disk. As a consequence, if the problem is not addressed by appropriate treatment and precautions, one day you may not be able to reduce the dislocation yourself.
3. Limited range of vertical mouth opening
4. Facial pain and muscle fatigue. The nerve to the TMJ is a branch of the trigeminal nerve and therefore, an injury to the TMJ may be confused with neuralgia of the trigeminal nerve.
5. Noises in the joints associated with jaw movements (clicking, snapping, crunching, etc.) Joint noises during jaw movements are a sign that the functional elements of the TMJ are not working smoothly. Crunching or grinding noises (crepitus) are associated with hard tissue contact during movements of the TMJ. There may or may not be pain in the joints. The condylar head is supposed to move together in sync on the depression of the articular disc. In internal derangement, the disk lies in front of its normal position when the mouth is closed. As the mouth opens and the jaw slides forward, the disk slips back into its normal position, making a clicking or popping sound as it does. As the mouth closes, the disk slips forward again, often making another sound. This clicking sound may sometimes be so loud, that others can hear it while you chew.

SECONDARY SYMPTOMS
1. Earaches not associated with any infection. Due to the close anatomical relationship of the TMJs to the ears, an injury to the TMJ often causes various ear symptoms. Some of the symptoms may be ear pain, fullness or stuffiness, ringing in the ears (tinnitus) and even a loss of hearing.
2. Frequent headaches. Headache is one of the most common symptoms of a TMJ problem. Usually the TMJ headache is located in the temples, back of the head, and even the shoulders. Clenching and grinding of the teeth may produce muscle pain that can cause headaches. These headaches are frequently so severe that they are confused and treated with little success for migraine headaches.
3. Neck \ shoulder pain. Pain will be felt in the shoulders and back due to muscle contraction, a condition called myofascial pain dysfunction syndrome.
4. Dizziness, disorientation and even confusion are also seen in some people.
5. Sensitive teeth. The teeth may become sensitive because of jaw activities such as clenching or grinding of the teeth when the disc of the TMJ is displaced. Patients often see their dentist with the complaint of pain in the teeth and usually the dentist cannot find any cause. Frequently (and very unfortunately), unnecessary root canals and even tooth extractions are performed.
6. Depression. This may be due to the fact that no one else really believes, there is a problem causing such pain and suffering. Scientific evidence shows that chronic pain patients have changes in their chemicals in the brain (neurotransmitters) as a result of the pain. These chemicals can produce depression. Along with depression comes an inability to get a good night's sleep. This may be due to TMJ pain itself or changes in the brain's neurotransmitter chemicals. Sufferers usually wakeup feeling like they never slept or did not sleep well. This lack of sleep not only makes their pain seem worse, but also adds fuel to the fire of depression.
7. Photophobia or light sensitivity. A dislocated TMJ may produce pain in and behind the eye, which can cause sensitivity to light. Blurred vision and eye muscle twitching are also common.

What are the causes for TMJ disorders?
1. Opening the mouth too wide. All joints have limitations of movements and the TMJ is no exception. If you open your mouth wide for a long time (yawning, biting into a large sandwich, etc) ligaments may be torn. Swelling and bruising develop and disc dislocation may occur.
2. Bruxism. Bruxism is the abnormal grinding of the teeth. Bruxism usually occurs during sleep. That is why so many people do not realize that they are bruxers. One indication that a person is a bruxer is sore jaw muscles when waking-up in the morning. Bruxism produces muscle pain and sensitive or worn teeth.
3. Malocclusion. Malocclusion (incorrect bite) may be produced by poor development of the jaws, removal of teeth, non-replacement of missing teeth, improper dental restoration, poor fitting dentures, etc. All this can lead to TMJ disorders.
4. Stress. Both physical and psychological stress can produce abnormal pressure on the TMJ disc causing TMJ disorders.
5. Systemic Diseases. Immune disorders such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus can produce inflammation in the TMJ. Viral infections such as mononucleosis, mumps and measles can cause damage to the surfaces of the TMJ.
6. Trauma. Whiplash injury during an accident or a direct trauma to the mandible or to the TMJ. Any injury that results in bleeding into the joints can even cause Ankylosis of the jaw.
7. Arthritis can affect the temporomandibular joints the same way it affects other joints. In Osteoarthritis the cartilage of the joints degenerates and is most common in older people. When osteoarthritis is severe, the top of the jawbone flattens out, and the person can't open the mouth wide.
Rheumatoid arthritis affects the temporomandibular joint in only about 17 percent of people. When rheumatoid arthritis is severe, especially in young people, the top of the jawbone may degenerate and shorten and the jawbone may eventually fuse to the skull (ankylosis), greatly limiting the ability to open the mouth. Rheumatoid arthritis usually affects both temporomandibular joints equally.
Arthritis in a temporomandibular joint may also result from injury, particularly injury that causes bleeding into the joint. Such injuries are fairly common in children who are struck on the side of the chin.
8. Hypermobility is looseness of the jaw. This results when the ligaments that hold the joint together become stretched. In a person with hypermobility, the jaw may slip forward completely out of its socket (dislocation), causing pain and an inability to close the mouth.
9. Developmental Abnormalities of the temporomandibular joint at birth. These are uncommon. Sometimes the top of the jawbone doesn't form or is smaller than normal. Other times, the top of the jawbone grows faster or for a longer time than normal. These abnormalities can cause facial deformities and misalignment of the upper and lower sets of teeth. Only surgery can correct these problems.

What are the treatments for TMJ disorders?
Eighty percent of people get better in 6 months without any treatment. There are two basic types of treatment for TMJ disorders: Surgical and Non-surgical. In general it is recommended that non-surgical therapy be provided for a period of six months prior to consideration of surgery.
NON-SURGICAL TREATMENT
1. Avoid opening the mouth wide when yawning or biting into a thick sandwich, etc. People with this condition need to stifle yawns, cut food into small pieces and eat food that's easy to chew.
2. Fabrication and insertion of an intra-oral splint, which may be fitted to either the upper or lower jaws (in some cases to both), to re-position the condylar head in the joint space to a more normal position. Thereby relieving the stresses and pressures being placed on the tissues of the joints and their related supporting structures. This eliminate muscle spasms, TMJ swelling, dislocation and generally reduce any type of pain.
3. Physiotherapy. These might include exercises, rehabilitation programs, ultra-sound, etc. Ultrasound is a method of delivering deep heat to painful areas. When warmed by the ultrasound, the blood vessels dilate, and the blood can more quickly carry away the accumulated lactic acid that may cause muscle pain.
Electromyographic biofeedback monitors muscle activity with a gauge. The patient attempts to relax the entire body or a specific muscle while watching the gauge. In this way, the patient learns to control or relax particular muscles.
Spray and stretch exercises involve spraying a skin refrigerant over the cheek and temple, so the jaw muscles can be stretched.
Friction massage and hot fermentation consists of rubbing or keeping a hot towel over the cheek and temple to increase circulation and speed lactic acid removal.
Transcutaneous electrical nerve stimulation involves using a device that stimulates the nerve fibers that do not transmit pain. The resulting impulses are thought to block the painful impulses the patient has been feeling.
4. Adjunctive medications in the form of anti-inflammatory, muscle relaxants and such other prescription medicines.
5. Stress Management. This can include any number of modalities from biofeedback training to counseling to medications.
6. Correct any discrepancies between the upper and lower jaws. May include adjustment of the dental occlusion, orthodontic treatment, replacement of missing teeth, etc.
7. Injections of local anesthetic and other medications (steroids) into the joint.
8. Treatment of any underlying systemic disease that could have caused this problem.
9. A person with osteoarthritis in a temporomandibular joint needs to rest the jaw as much as possible. Even without treatment, most of the symptoms improve after a few years, probably because the band of tissue behind the disk becomes scarred and functions like the original disk. If ankylosis freezes the jaw, the person may need surgery and in rare cases, an artificial joint to restore jaw mobility.

SURGICAL TREATMENT
In general it is recommended that non-surgical therapy be provided for a period of six months prior to consideration of surgery. When all else fails, removal or rearrangement of the parts offers a last opportunity to resolve the problem. A variety of surgical treatments have been suggested to achieve this ---- arthrocentesis, arthroplasty, condylotomy, condylectomy, high condylectomy (condylar shave) with and without replacement, and TMJ reconstruction.
1. ARTHROCENTESIS consists of anesthetizing the affected TMJ with local anesthetic followed by flushing the joint with a sterile solution such as Lactated Ringers Solution. A relatively simple in-office procedure that allows expansion of the joint space, lysis of adhesions and lavage via blind input and outflow catheters. The effect of TMJ arthrocentesis is to lubricate the joint surfaces and reduce inflammation. Corticosteroids or anti-inflammatory agents can be injected into the joint following arthrocentesis. Gentle manipulation of the jaw is often utilized following arthrocentesis to improve the jaw range of motion and in some cases lyse or break fibrous adhesions that limit normal jaw opening.
Disadvantages include: lack of visualization, only limited ability to lyse adhesions, almost no ability to reposition the disk except via insufflation of the joint space and indirect manipulation. Many practicioners consider a diagnostic / therapeutic intracapsular injection to be a variant of arthrocentesis. In this case, there is no outflow catheter but medications may be instilled into the joint space and the capsule is certainly insufflated by the amount of fluid in the injection. The good results with this relatively risk-free procedure suggest that its use is preferable to arthroscopic or open surgery in the initial management of most patients with nonreducing or adherent discs.

2. ARTHOTOMY is the cutting into a joint or open joint surgery. Open joint surgery is done through an incision over the joint area in front of the ear. The incision usually extends from inside the sideburn area, then in front of the top of the ear, extending into the ear itself. The incision that extends into the ear is placed there to hide the incision from view. The flap is then brought forward to expose the underlaying layers. The fascial layer (fibrous membrane covering) is exposed and brought forward to expose the joint capsule. Once the capsule is opened exposing the disc, a full examination of joint can be made. Careful examination is performed of all the soft and bony tissue identifying displacement, perforations, rough surfaces, sharp edges, cavities or anatomical abnormalities. The disc is also examined for position, smoothness, and flexibility. After the surgery is complete, the joint incision is closed. The skin is closed with some dissolvable sutures and a dressing applied over the wound. A pressure bandage maybe applied to reduce the swelling.
# Arthroplasty / Meniscoplasty / Discoplasty These procedures involve surgical repositioning of the meniscus (disc). This is an open joint procedure to correct or improve the contour of an intra-articular disc. If the disc is healthy enough, it is usually repaired (disc plication). Repair involves pulling the disc into a more normal position and holding it there with sutures (stitches). If the disc is abnormally stretched out it is “tightened” by taking a wedge of tissue out behind the disc and suturing the edges together. Repair of a perforated disc is sometimes performed if adequate soft tissue still exists.
Condylotomy or fossaplasty or both are often performed in conjunction with arthroplasty.
# Meniscectomy / Discectomy. The indications for meniscectomy/discectomy are irreparable disc perforation, function-impeding disc deformation, and extensive arthritic deterioration. Discectomy is an open joint procedure with complete removal of the intra-articular disc. A discectomy can be performed either without or with replacement of the disc. If the bony surfaces are very rough or if a great deal of bone has been eroded, a graft of the patient’s own tissue may be used as a substitute. The bony surfaces are examined and any excessively rough surfaces are smooth out with surgical files. There are a variety of autogenous grafts (your own tissue) that are used for disc replacements such as; temporalis fascia/muscle, fascia lata (hip), auricular cartilage (ear), dermis (skin). Using an autogenous graft usually requires an additional surgical site where the graft is harvested (taken). The use of alloplastic interpositional materials such as Silastic or Proplast-Teflon was originally reported to be highly successful, but subsequent studies showed that such implant under function produced a severe foreign body reaction associated with bone destruction and pain. As a result, these materials were withdrawn from the market.
The condylar articular surface is recontoured to correct areas of arthritic change. On occasion, if additional joint space is required, a condylotomy or fossaplasty or both may be performed.
# Condylotomy / Condyloplasty / Condylectomy. A condylotomy or condyloplasty is a surgical division or reshaping of the condyle, while a condylectomy is the surgical removal of the entire mandibular condyle. Condylotomy and condylectomy are performed infrequently. These procedures have been indicated for more complex disease or traumatic conditions. With these procedures, there can be more post-surgical complications, including marked occlusal changes.
# Eminectomy / modified condylotomy / fossaplasty. Increasing the functional joint space (Superior joint decompression) may be accomplished by eminectomy. A prominent and steeply angulated eminence is often associated with meniscal (disc) displacement, so reduction of the eminence and a decrease of the incline of the posterior slope may serve to increase the anterior joint space.

3. ARTHROSCOPIC. Where patient is not a candidate for open surgery, arthroscopic surgery may be useful. A highly touted form of treatment in some surgeons hands and spurned by others, this modality allows visual access to the joint space. As a diagnostic tool it's greatest strength is the ability to "see" and record the state of the hard and soft tissues of the joint. Since the introduction of arthroscopic surgery of the TMJ in the 1980s, this modality has also been used extensively to treat anterior disc displacement with reduction. The arthroscope is a telescope-like (endoscope) instrument that is placed into the upper TMJ space through a very small incision directly in front of the ear, through which the contents of the joint can be reviewed. Arthroscopy allows direct observation of movement, photographic and video documentation, and sampling of the joint tissues for a biopsy. This procedure allows diagnosis and selection of appropriate therapy. Corrective procedures such as lysis (breaking up) of scar tissue and lavage (irrigating/washing out) or combining these methods with disc repositioning and stabilization by using cautery or sutures can also be preformed.

4. RECONSTRUCTION \ REPLACEMENT. Autologous or alloplastic reconstruction is employed when persistent active hyperplasia or tumours (neoplasia) necessitates condylectomy, when the condyle is lost in trauma, or when condylar agenesis or hypoplasia results in a deficient mandibular growth. The bony destruction of degenerative joint disease, rheumatoid arthritis or congenital fibrous ankylosis of the jaws occasionally is an indication for this procedure. A total joint replacement surgery requires two incisions on the face/neck. The upper incision is made over the joint area in front of the ear, the same as described for any open joint procedure. The lower incision is usually made in a skin crease on the neck in an attempt to camouflage the scar. This incision is made through the tissues of the neck until the mandible is encountered. This incision exposes the part of the lower jaw where the graft is screwed into place. The lower incision is connected to the upper incision through a tunnel under the tissues. Before any of the incisions are made, the patient’s jaws are wired together. This is done to immobilize the teeth and place the occlusion in the right position. Some surgeons choose to leave the patient wired for a few days to a week. Other surgeons will remove the fixation at the conclusion of the surgery. The condyle is cut off to allow room for the graft. The fossa (socket) is smoothed. The graft is then shaped and fit into position before it is attached to the lower jaw with bone screws.
There are several different autogenous bony grafts that have been used in the repair of the TMJ. However, the costochondral (rib) graft has the longest, most extensive documentation as a substitute for the mandibular condyle.
Alloplastic reconstruction of total TMJ can be done with Implants. Reconstruction may require the use of both the fossa and condylar prostheses, resurfacing, or replacement of two articular surfaces. In some instances the fossa may not be deficient but will need protection of its surface from the high load and erosive forces caused by the metal condylar prosthesis. Artificial TMJ device design is a delicate interaction between engineering considerations and principles, surgical technique and requirements, functional demand, anatomical boundary limitations and biocompatibility.
TMJ total and partial (fossa only) joint replacement should be indicated for extremely rare cases. There have been some patients whose TMJ’s have reacted unfavorably to implant materials placed into them. This resulted in loss of bone over time leaving these patients with distorted joint anatomy, poor movement, and compromised jaw function.

What are the other pain disorders that are confused with TMJ disorders?
1. TEMPORAL TENDINITIS has been called "The Migraine Mimic" because many symptoms are similar to migraine headache pain. Symptoms include: TMJ pain, ear pain and pressure, temporal headaches, cheek pain, tooth sensitivity, neck and shoulder pain. Treatment consists of injecting local anesthetics and other medications, a soft diet, using moist heat fermentations, muscle relaxants and anti-inflammatory medications, physiotherapy, etc. Only rarely surgery is needed.
2. TRIGEMINAL NEURALGIA
3. ERNEST SYNDROME. This TMJ-like problem involves the stylomandibular ligament. This is a tiny structure that connects the base of the skull with the mandibular (lower jaw). If injured, this structure can produce pain in regions of the face, head and neck, TMJ, ear, eye, throat (especially when swallowing), lower back teeth and jaw bone, etc. Treatment of Ernest syndrome, which is successful about 80% of the time, consists of injections of local anesthetic and medication (steroids), physiotherapy, the use of an intraoral splint, styliodectomy, etc.
4. OCCIPITAL NEURALGIA. This disorder is characterized by pain located in the cervical and posterior regions of the head (occipital areas), which may or may not radiate into the sides of the head and into the facial and frontal regions. There are two major types of occipital neuralgia: lesser occipital and greater occipital. The lesser type is more common. The symptoms are : the pain may or may not be limted to one side, pain radiation from back of the head onto the sides, temple, cheek or forehead, pain above and behind the eye, severe light sensitivity, nausea when pain is severe, and pain radiating into ear, shoulder and arm.

131

Temporomandibular Joint (TMJ) Syndrome What is temporomandibular joint syndrome? Temporomandibular joint (TMJ) syndrome is a condition that causes frequent pain in the jaw joint. The pain occurs where the jaw meets the skull, just in front of the ear on each side of the face. Another term for this disorder is myofascial pain dysfunction of the jaw.

TMJ syndrome is more common in women than men.

How does it occur?

The cause of TMJ is not known. Possible causes of TMJ are:

Frequent clenching of the jaw or grinding of the teeth (the most common cause). You may clench your jaws or grind your teeth when you are feeling stressed or sleeping. If you do it mainly when you are sleeping, you may not even know you are doing it.
Ill-fitting dentures.
Frequent chewing of gum or ice.
Anatomic or dental abnormalities, such as problems of teeth alignment.
Injury from, for example, prolonged or repeated opening of the jaw or a direct blow to the joint. Pain from the injury may seem to go away after just a short time, but months to years later painful traumatic arthritis may develop in the joint.
Other forms of arthritis in the jaw, such as rheumatoid arthritis or osteoarthritis.

What are the symptoms?

The most common symptom is pain in the jaw joint. The pain is usually dull but sometimes sharp. In most cases the pain is worse when you move your jaw, especially when you are chewing. If you are grinding your teeth at night, the pain may also be worse first thing in the morning.

Other possible symptoms are:

clicking, popping, or grating sounds when move the jaw
trouble completely opening your jaw or an uncomfortable bite
headache
ear pain or earache.

The painful symptoms of TMJ syndrome can be similar to the symptoms of other conditions, such as ear problems. For this reason, you should see your health care provider about the pain.

How is it diagnosed?

Your health care provider will want to know when your jaw hurts and how long it has been hurting. He or she will ask if your jaw has been injured or if you have had dental work recently.

Your health care provider will examine your jaw for tenderness and check how it moves. An x-ray may be taken.

How is it treated?

To help relieve your symptoms:

Avoid overusing your jaw. Rest your jaw by eating only soft food. Do not chew gum or ice.
Try not to clench your jaw or grind your teeth. Your health care provider may recommend a bite block, a plastic mouthpiece that stops the teeth from grinding together. Bite blocks are usually worn only at night.
Apply a heating pad set at low for 20 minutes, 4 to 8 times a day.
Put a cloth-covered ice pack on your jaw for 20 minutes 4 to 8 times a day.
Ask your health care provider about taking an anti-inflammatory medicine, such as ibuprofen, to help the joint become less irritated. In some cases your provider may recommend a shot of steroid or cortisone in the joint to treat the inflammation.

Other treatments may include taking muscle relaxants for a few days, using relaxation techniques, and learning ways to have less stress. Your health care provider may refer you to a physical therapist for treatment, such as massage and exercises that gently stretch the muscles and help with relaxation. If your pain is clearly related to stress, counseling and medicine can help.

If there is a problem with the way your teeth fit together when you bite, you may need to see a dentist.

Surgery is rarely necessary. Before you have jaw surgery, get a second opinion, preferably from a health care provider who specializes in TMJ syndrome.

How can I help prevent TMJ syndrome?

Because the cause of TMJ is not known, doctors do not know how to prevent it. But the following may help:

Avoid overusing your jaw (for example, avoid chewing gum or ice).
Try not to grind your teeth.

132 Temporomandibular Joint (TMJ) Syndrome
Alternate Names : TMJ or TMD Pictures & Images

Causes of Secondary Headache

133 TMJ disorders

Contents of this page:
Illustrations Alternative names Definition Causes, incidence, and risk factors Symptoms Signs and tests	Treatment Support Groups Expectations (prognosis) Complications Calling your health care provider Prevention

Illustrations

Skull of an adult

Causes of secondary headache

Alternative names Return to top

TMD; Temporomandibular joint disorders

Definition Return to top

The temporomandibular joints (TMJs) connect your lower jaw to your skull. There are two matching joints -- one on each side of your head, located just in front of your ears. The abbreviation "TMJ" literally refers to the joint but is often used to refer to any disorders or symptoms of this region. Such problems include popping sounds in the jaw, inability to fully open the mouth, jaw pain, headaches, earaches, toothaches, and various other types of facial pain.

Causes, incidence, and risk factors Return to top

Many TMJ-related symptoms are caused by the effects of physical and emotional stress on the structures around the joint. These structures include the muscles of the jaw, face, and neck; the teeth; the cartilage disc at the joint; and nearby ligaments, blood vessels, and nerves.

For example, daily stress can lead you to clench and grind your teeth, both during the day and at night while you sleep. Clenching means you tightly clamp your top and bottom teeth together, especially the back teeth. The stressful force of clenching causes pressure on the muscles, tissues, and other structures around your jaw.

Many people who clench also grind their teeth. Grinding is when you slide your teeth over each other, generally in a sideways, back-and-forth movement. This action may wear down your teeth and be noisy enough at night to bother sleeping partners.

Poor posture can also be an important factor. For example, holding the head forward while looking at a computer all day strains the muscles of the face and neck.

Other factors that might aggravate TMJ symptoms are inability to relax, poor diet, and lack of sleep.

All of these stresses can result in "trigger points" -- contracted muscles and pinched nerves in your jaw, head, and neck. Trigger points can refer pain to other areas, causing a headache, earache, or toothache.

Other possible causes of TMJ-related symptoms include arthritis, fractures, dislocations, and structural problems present since birth.

Symptoms Return to top

Headache
Earache (the joint is located right in front of the ears and can easily be interpreted as ear pain; in addition, pain may be referred to the ear from nearby muscles)
Jaw pain or tenderness of the jaw
Dull, aching facial pain
Biting or chewing difficulty or discomfort
Clicking sound while chewing or opening the mouth
Grating sensation while chewing
Reduced ability to open or close the mouth

Signs and tests Return to top

TMJ pain and symptoms may require evaluation by more than one medical specialty, such as your primary care provider, a dentist, or an ear, nose, and throat (ENT) doctor, depending on your symptoms. Some dentists specialize in TMJ diagnosis and treatment.

A thorough examination may involve:

Feeling the joint and connecting muscles for tenderness
Watching, feeling, and listening to the jaw open and shut
Sliding the teeth from side to side
Pressing around the head for areas that are sensitive or painful
X-rays which may show abnormalities, but can be difficult to read
An MRI of the jaw area may occasionally be performed
A dental examination may show mis-alignment of the bite (crossbite, malocclusion)

In some cases, the results of the physical examination may appear normal.

Treatment Return to top

Simple, gentle therapies are usually recommended first. If those don't work, mouth guards and more aggressive treatments may be considered. Surgery is generally considered a last resort. Fortunately, there are many steps you can take at home long before that point.

Try massaging the various muscles that may be involved. Probe all of the muscles of the face, shoulders, and back of the neck. (Avoid the area around the throat.) Press on the muscles to identify extremely painful points. Massage the painful spot with hard, slow, short strokes. Do this several times a day until the muscle is no longer painful when pressed.

To massage the masseter muscles on each side of your jaw, place your thumb inside your mouth and squeeze the thick muscle in your cheek (toward the back of your mouth) with your fingers. To get at the harder-to-reach jaw muscles inside your mouth, use your index finger to probe for tender areas behind the teeth, and use the finger to massage these spots.

Here are some other steps to consider:

Maintain good posture while working at a computer, watching TV, and reading. Take frequent breaks to relieve stressed muscles.
Make a habit of relaxing your facial and jaw muscles throughout the day.
Avoid eating hard foods, like nuts, candies, and steak.
Drink plenty of water every day and get plenty of sleep.
Learn relaxation techniques to reduce overall stress and muscle tension in your back, neck, and body.

Other home-care therapies are useful for some people, such as moist heat or cold packs on the face, vitamin supplements, or biofeedback. Exercising several times each week may help you relax, strengthen your body, increase flexibility, and increase your pain threshold.

Read as much as you can, as opinion varies widely on the management of TMJ disorders. Get several clinical perspectives. The good news is that most people eventually find something that helps.

MOUTH GUARDS

Mouth guards, also called splints or appliances, have been used since the 1930's to treat teeth grinding, clenching, and TMJ disorders. Many people have found them to be useful, but the benefits vary widely. The guard may lose its effectiveness over time, or when you stop wearing it. Other people may feel worse pain when they wear one.

There are different types of splints. Some fit over the top of the teeth, some on the bottom. They may be designed to keep your jaw in a more relaxed position, inhibit clenching, or provide some other function. If one type doesn't work, another may.

For example, a new type of splint is called the NTI-tss. It fits over just a couple of top, front teeth. The idea is to keep all of your back teeth completely separated, under the theory that most clenching is done by these back teeth. With the NTI splint, the only contact is between the tiny splint and one bottom front tooth.

MORE AGGRESSIVE TREATMENT

Be cautious about any non-reversible treatment method that permanently alters your bite. However, if a mouth guard doesn't work, your dentist may recommend orthodontics to help re-align your teeth.

Reconstructive surgery of the jaw is rarely required. In fact, studies have shown that the results are often worse than before surgery.

Muscle relaxant medications may help. Nonsteroidal anti-inflammatory medications (NSAIDS) help reduce inflammation in the jaw stemming from arthritis or other causes of inflammation.

Support Groups Return to top

For additional information, two excellent books are Taking Control of TMJ by Robert Uppgaard and The Trigger Point Therapy Workbook by Clair Davies.

Expectations (prognosis) Return to top

Most cases can be successfully treated, although initially it may be difficult to diagnose the problem and find an effective solution. Some cases of pain go away on their own without treatment. TMJ-related pain tends to be cyclical and may return again in the future. If the cause is nightime clenching, treatment can be particularly tricky because it is a sleeping behavior that is hard to control.

Mouth splints are a common treatment approach for teeth grinding. While some splints may silence the grinding by providing a flat, even surface, their effectiveness at reducing pain or stopping clenching is more controversial. Splints may be effective in the short-term but could become less effective over time. Splints can also cause changes in your bite.

Complications Return to top

Chronic headaches
Chronic facial pain

Calling your health care provider Return to top

See a TMJ specialist immediately if you are having trouble eating or opening your mouth. Keep in mind that a wide variety of possible conditions can cause TMJ symptoms, from arthritis to whiplash injuries. Therefore, see a TMJ specialist for a full evaluation if self-care measures do not help within several weeks.

TMJ problems do not fall clearly into one medical discipline, and TMJ specialists have a wide variety of treatment approaches. If you are interested in a massage-based approach, look for a massage or physical therapist trained in trigger point therapy, neuromuscular therapy (NMT), clinical massage, or pain relief, particularly as it applies to TMJ pain.

Dentists who specialize in evaluating and treating TMJ disorders will typically perform x-ray exams and prescribe a mouth guard. Surgery is now considered a last resort by the vast majority of TMJ experts.

Prevention Return to top

Many of the home-care steps to treat TMJ problems can prevent such problems in the first place:

Maintain good posture, especially if you work all day at a computer. Pause frequently to change position, rest your hands and arms, and relieve stressed muscles.
Learn relaxation techniques to reduce overall stress and muscle tension.
Avoid eating hard foods and chewing gum.
Drink plenty of water every day and get plenty of sleep.
Use safety measures to reduce the risk of fractures and dislocations.

Update Date: 5/13/2004

137

Current Age	Life Expectancy
50	30 years
55	28 years
60	24 years
65	20 years
70	16 years
75	12 years
80	9 years
85	6 years
90	5 years

(data from IRS Publication 590, Appendix E, Table 1, December 12, 1999)

Temporomandibular Joint (TMJ) Syndrome

(Temporomandibular Joint Disorder; Temporomandibular Joint Dysfunction; Myofacial Pain Dysfunction Syndrome)

by Jenna Hollenstein, MS, RD

Definition

Temporomandibular joint syndrome is a painful condition involving the joint that opens and closes the mouth. The temporomandibular joints are the small joints in front of each ear that attach the lower jaw (mandible) to the skull. The disorder may affect the jaw joint or the muscles surrounding it.

The Temporomandibular Joint

factsheet image

Causes

The exact cause of TMJ syndrome is often unclear. Possible causes include:

Excess tension in the jaw muscles
Faulty alignment between the upper and lower teeth and jaws
Disturbed movement of the jaw joint
Displacement or abnormal position of the jaw joint or cartilage disc inside the jaw joint
Inflammation of the joint
Excess or limited motion of the joint
Injury of the jaw or face

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

Sex: female
Age: 30-50 years old
Clenching or grinding of teeth
Poorly fitting dentures
Fibromyalgia
Stress
Arthritis

Symptoms

Symptoms include:

Pain in the temporomandibular joint or the jaw
Pain that may be worse with chewing, yawning, or opening the mouth
Clicking, popping, or grating sounds with movement of the jaw
A sensation of the jaw ?catching? or ?locking? briefly, while attempting to open or close the mouth, or while chewing
Difficulty opening the mouth completely
A bite that feels "off," uncomfortable, or as if it is frequently changing
Swelling in the affected side of the face or mouth
Muscle pain/spasm in the area of the temporomandibular joint
Facial pain
Headache
Earache
Neck, back and/or shoulder pain

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. The physical exam may include:

Range of motion tests
Listening for sounds in the joints
Examining your teeth, jaw joints, and muscles of your face and head
Palpation of the jaw joints and the muscles of the face and head

Other tests may include:

X-rays ? plain x-rays or panoramic dental x-rays of the jaw and jaw joint. They show the bony structures well but not soft tissues.

Arthrogram ? x-rays taken after dye is injected into the jaw joint. Sometimes the movements of the jaw are videotaped.

Tomogram ? can show x-ray "slices" through the joint

CT Scan ? a type of x-ray that uses a computer to make pictures of the inside of the jaw joint

MRI Scan ? a test that uses magnetic and radio waves to make pictures of the inside of the jaw joint

Treatment

Treatment may include:

Pain Relief

A soft diet may be recommended to reduce pain while chewing. Pain can be treated with warm or cold packs, restriction of jaw movement, or medications. The most commonly used medicines are acetaminophen, nonsteroidal anti-inflammatory drugs, muscle relaxants, and antidepressants. In some cases the jaw joint may be injected with pain relieving medicine such as cortisone or lidocaine.

Physical Therapy

Gentle massage or stretching exercises, transcutaneous electrical nerve stimulation (TENS), and biofeedback may reduce pain and help muscles to relax.

Stress Reduction

Counseling to learn stress management and relaxation techniques may help some patients with TMJ.

Dental Procedures

A splint or mouth guard can be made that you wear in your mouth to relax your jaw muscles and prevent clenching and grinding of your teeth. Correction of bite abnormalities by a dentist or orthodontist is sometimes recommended.

Surgical Procedures

Surgical correction may be a last resort if other treatments have not succeeded and the pain becomes unbearable. Many of the available procedures have not been scientifically proven to treat TMJ syndrome. Types of surgery include:

Arthroplasty ? procedures that involve operating on the jaw joint

Condylotomy ? surgical removal of part of the jaw bone

Prevention

There are no guidelines for preventing TMJ. If you have TMJ, the following may help prevent symptoms:

Ask your dentist if you need a night guard for grinding and clenching of the teeth
Don't use a pillow for sleeping.
Try to limit jaw movements and learn to relax your jaw. Block a yawn by putting your fist under your chin.
Avoid yelling or loud singing.
Don't chew gum.
Learn relaxation techniques and better, healthier ways to cope with stress.

RESOURCES

The TMJ Association
http://www.tmj.org/

139 Temporomandibular Joint (TMJ) Syndrome

What is temporomandibular joint syndrome?

Temporomandibular joint (TMJ) syndrome is a condition that causes frequent pain in the jaw joint. The pain occurs where the jaw meets the skull, just in front of the ear on each side of the face. Another term for this disorder is myofascial pain dysfunction of the jaw.

TMJ syndrome is more common in women than men.

How does it occur?

The cause of TMJ is not known. Possible causes of TMJ are:

Frequent clenching of the jaw or grinding of the teeth (the most common cause). You may clench your jaws or grind your teeth when you are feeling stressed or sleeping. If you do it mainly when you are sleeping, you may not even know you are doing it.
Ill-fitting dentures.
Frequent chewing of gum or ice.
Anatomic or dental abnormalities, such as problems of teeth alignment.
Injury from, for example, prolonged or repeated opening of the jaw or a direct blow to the joint. Pain from the injury may seem to go away after just a short time, but months to years later painful traumatic arthritis may develop in the joint.
Other forms of arthritis in the jaw, such as rheumatoid arthritis or osteoarthritis.

What are the symptoms?

Other possible symptoms are:

clicking, popping, or grating sounds when move the jaw
trouble completely opening your jaw or an uncomfortable bite
headache
ear pain or earache.

The painful symptoms of TMJ syndrome can be similar to the symptoms of other conditions, such as ear problems. For this reason, you should see your health care provider about the pain.

How is it diagnosed?

Your health care provider will want to know when your jaw hurts and how long it has been hurting. He or she will ask if your jaw has been injured or if you have had dental work recently.

Your health care provider will examine your jaw for tenderness and check how it moves. An x-ray may be taken.

How is it treated?

To help relieve your symptoms:

Avoid overusing your jaw. Rest your jaw by eating only soft food. Do not chew gum or ice.
Try not to clench your jaw or grind your teeth. Your health care provider may recommend a bite block, a plastic mouthpiece that stops the teeth from grinding together. Bite blocks are usually worn only at night.
Apply a heating pad set at low for 20 minutes, 4 to 8 times a day.
Put a cloth-covered ice pack on your jaw for 20 minutes 4 to 8 times a day.
Ask your health care provider about taking an anti-inflammatory medicine, such as ibuprofen, to help the joint become less irritated. In some cases your provider may recommend a shot of steroid or cortisone in the joint to treat the inflammation.

If there is a problem with the way your teeth fit together when you bite, you may need to see a dentist.

Surgery is rarely necessary. Before you have jaw surgery, get a second opinion, preferably from a health care provider who specializes in TMJ syndrome.

How can I help prevent TMJ syndrome?

Because the cause of TMJ is not known, doctors do not know how to prevent it. But the following may help:

Avoid overusing your jaw (for example, avoid chewing gum or ice).
Try not to grind your teeth.

140 Medications for Temporomandibular Joint (TMJ) Syndrome

by Rosalyn Carson-DeWitt, MD

The information provided here is meant to give you a general idea about each of the medications listed below. Only the most general side effects are included, so ask your health care provider if you need to take any special precautions. Use each of these medications as recommended by your health care provider, or according to the instructions provided. If you have further questions about usage or side effects, contact your health care provider.

There are no medications that are specifically designed to treat TMJ syndrome. However, if you are having a lot of pain and discomfort, your health care provider might recommend either a prescription or an over-the-counter pain reliever, muscle relaxant, or antidepressant (a type that is used to treat chronic pain). These medicines are usually used occasionally or for very brief periods of time. Check with your health care provider to determine exactly how long you should be using these types of medicines.

P Prescription Medications

Minor tranquilizers

Diazepam (Diastat, Diazepam Intensol, Dizac, Valium)
Alprazolam (Alprazolam Intensol, Xanax)

Tricyclic antidepressants

Amitriptyline (Elavil, Endep)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Imipramine (Norfranil, Tipramine, Tofranil)
Nortriptyline (Aventyl, Pamelor)

O Over-the-Counter Medications

Acetaminophen

Actamin
Banesin
Tylenol

Ibuprofen

Advil
Excedrin IB
Motrin
Nuprin

P Prescription Medications

Minor Tranquilizers

Common names include:

Diazepam (Diastat, Diazepam Intensol, Dizac, Valium)
Alprazolam (Alprazolam Intensol, Xanax)

Minor tranquilizers are generally reserved for very severe cases of TMJ syndrome. These medications have general and muscle relaxing effects, and may help relieve some of the pain in your jaw and muscles. They may help you avoid grinding your teeth and/or clenching your jaw while you sleep. They may also relieve anxiety, and thereby might make it easier for you to stop grinding your teeth and/or clenching your jaw during the day.

These medicines are usually prescribed for use at night, and for a very brief time (usually less than a month).

Possible side effects include:

May be habit-forming if used for a long period of time
Daytime drowsiness
Dizziness

Dont take these medicines with alcohol or with other medicines that can cause drowsiness (including other sedatives, pain medications, antihistamines, sleeping pills, etc.).

Tricyclic Antidepressants

Common names include:

Amitriptyline (Elavil, Endep)
Clomipramine (Anafranil)
Desipramine (Norpramin)
Imipramine (Norfranil, Tipramine, Tofranil)
Nortriptyline (Aventyl, Pamelor)

Tricyclic antidepressant drugs have been found to be effective for treating chronic pain of severe TMJ syndrome. These medicines are usually prescribed for use at night, and for a very brief time (usually less than a month).

Possible side effects include:

Daytime drowsiness
Dizziness
Dry mouth
Increased sun sensitivity

Dont take these medicines with alcohol or with other medicines that can cause drowsiness (including other sedatives, pain medications, antihistamines, sleeping pills, etc.).

Over-the-Counter Medications

Acetaminophen

Common brand names include:

Actamin
Banesin
Tylenol

Acetaminophen can be helpful in relieving some of the jaw and muscle pain associated with TMJ syndrome. Its also safe to give to children. Do not take a larger dose than is recommended by your health care provider. Do not drink alcoholic beverages while you are taking acetaminophen.

Ibuprofen

Common brand names include:

Advil
Excedrin IB
Motrin
Nuprin

Ibuprofen can also help relieve some of the jaw and muscle pain and inflammation associated with TMJ syndrome. Because some people find ibuprofen to be very hard on the stomach, you should take this medicine with food. Drinking alcoholic beverages while you are taking ibuprofen can increase the chance that it will irritate your stomach.

On rare occasions, people have allergic reactions to ibuprofen. If you notice a new skin rash, difficulty breathing, or puffiness or swelling in your face or around your eyes, stop taking ibuprofen and immediately contact your health care provider.

S Special Considerations

Whenever you are taking a prescription medication, take the following precautions:

Take them as directed, not more, not less, not at a different time.
Do not stop taking them without consulting your health care provider.
Dont share them with anyone else.
Know what effects and side effects to expect, and report them to your health care provider.
If you are taking more than one drug, even if it is over-the-counter, be sure to check with a physician or pharmacist about drug interactions.
Plan ahead for refills so you don't run out.

142
TITLE: Temporomandibular Joint Disorders Overview

SOURCE: The University of Texas Medical Branch
DATE: March 11, 1998
RESIDENT PHYSICIAN: Michael E. Prater, MD
FACULTY PHYSICIAN: Byron J. Bailey, MD
SERIES EDITOR: Francis B. Quinn, Jr., MD

"This material was prepared by physicians in partial fulfillment of educational requirements established for Continuing Postgraduate Medical Education activities and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a interactive computer mediated conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of subscribers or other professionals and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."

http://www.utmb.edu/otoref/Grnds/tmj-1998/tmj.htm

Although no specific data exists regarding the social impact of temporamandibular joint disorders, TMJ is estimated to account for as much as thirty billion dollars a year in lost productivity. Americans lose 550 million work days every year due to symptoms associated with TMJ, with facial pain and headache being the most common complaints. Accordingly, analgesics directed at these symptoms are among the top selling over the counter medicines in our society.

Despite the lack specific data regarding the incidence of these disorders, much has been learned over the last decade regarding specific pathology and therapy. Generic terms such as TMJ Syndrome, or Myofascial Pain Dysfunction Syndrome (MPD Syndrome) are generally outdated. It is now possible to differentiate between true muscular disorders and those disorders with pathological changes of the temporomandibular joint.

The term temporomandibular joint disorders is an umbrella term which combines those with true pathology of the temporomandibular joint and those with involvement of the muscles of mastication (myofascial pain dysfunction). Much of the difficulty encountered with the treatment of these patients is attributed to the physicians inability to accurately diagnose the disorder.

Anatomy

Painful disorders of the temporomandibular joint involve the trigeminal nerve. There are three branches of the nerve that have their sensory synapses in the trigeminal ganglion: the ophthalmic (V1), maxillary (V2) and mandibular (V3). Each branch also contains motor fibers, which innervate the muscles of mastication. Pain receptors are divided into two groups, depending on their size, myelination and rate of transmission. The larger A delta fibers are myelinated and therefore transmit pain quickly, and are the most important pain fibers. The smaller, nonmyelinated fibers, or C fibers, are more susceptible to chronic, dull, pain and pressure. Both pain fibers have input from the trigeminal ganglia to the spinal nucleus, with subsequent synapses leading to the postcentral gyrus and the reticular activating system. This helps explain the highly emotional component of facial pain.

Other areas innervated by the trigeminal nerve helps explain referred pain from the temporomandibular joint. Included are the dura mater, orbit, paranasal sinuses, tympanic membrane, oral cavity and teeth, helping explain headaches, eye pain, sinus pressure, otalgia and dental pain, respectively.

The muscles of mastication are abductors (jaw opening) and adductors (jaw closing) muscles. The temporalis, masseter and medial pterygoids are adductors, while the lateral pterygoids are the primary abductors of the jaw.

The temporomandibular joint consists of the mobile condyloid process of the mandible which articulates with the glenoid fossa of the temporal bone. The anterior portion of the glenoid fossa is the articular eminence. Posteriorly lies the external auditory canal. Laterally is the zygomatic process, and medially is the styloid process. The surface of the condylar and glenoid fossae are lined with fibrous connective tissue which is primarily a layer of hyaline cartilage. This thin, unprotected cartilage, particularly on the condylar process, is an important growth center. Damage to this cartilage can result in dysmorphic growth of the mandible and, by extension, the maxilla. Therefore, any alteration in the cartilaginous layers in a child is a cause for great concern regarding facial growth.

Between the condylar process and the glenoid fossa lies an interposed cartilaginous disc. The disc provides a stable platform for the rotational and gliding movements of the joint. It also acts as a shock absorber. An alteration in the normal position of the disc is known as an internal derangement. The mandible is held in position by a set of several ligaments. Medially and laterally are the capsular ligaments, and posteriorly is the meniscotemporomandibular frenum (retrodiscal pad). More posteriorly and medially are the stylo- and sphenomandibular ligaments. Finally, the tendons of the muscles of mastication also suspend the mandible.

In the healthy joint, the disc and condyle are considered one continuous anatomical structure. The lateral and medial ligaments and the retrodiscal pad have connections between the disc and the condyle. Therefore, the essential cause of disc disorders is a pathologic change in the ligamentous attachments of the disc-condyle complex..

Anterior to the condyloid process is the coronoid process of the mandible. The notch between the two is known as the incisura mandibularis, or the sigmoid notch. The temporalis tendon inserts along the coronoid process, and the masseter has a broad insertion along the lateral border. Passing over the sigmoid notch is the masseteric artery, a branch of the maxillary artery, which along with other branches of the internal maxillary artery supply the joint capsule.

Diseases and Disorders of the TMJ

The temporomandibular joint is susceptible to all the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies and neoplasms. Although treatment is often similar to other joints in the body, some variations exist.

Myofascial pain disorders are the most common cause of pain in the head and neck, and those involved in the temporomandibular joint are no exception. The complex symptomatology and frequent psychosocial factors often make these disorders difficult to treat. Once diagnosed, however, treatment is usually effective if compliance is maintained. The muscles of mastication are primarily involved, and the condition is characterized by a unilateral dull, aching pain which increases with muscular use. Common complaints associated with referred pain include headache, otalgia, tinnitus, burning tongue and sometimes decreased hearing.

There is believed to be a large psychosocial component of this disease. Increased stress levels are believed to result in poor habits, including bruxism, clenching and even excessive gum chewing. These lead to muscular overuse, fatigue and spasm, and subsequently, pain.

Muscular disorders consist of a group of diagnoses that are characterized by pain from pathologic or dysfunctional changes in a muscle group, and there are at least six recognized disorders of the head and neck. Myositis is an acute condition with inflammation of the muscle and connective tissue with associated pain and edema and a decreased range of motion. Etiologies include overuse, infection or trauma. Muscle spasm is considered an acute contraction of a muscle caused by an overstretching or overuse of a muscle. If left untreated in the contracted state, fibrous scarring and contracture will develop. Hysterical trismus refers to decreased range of motion which is due to psychological causes. Fibromyalgia is a diffuse, systemic muscular process whereby areas of firm, painful bands are found in weight bearing muscles, often with an associated sleep disorder. There is no evidence of arthritis or myositis, and there is a female preponderance. There is often associated bruxism and arthritis, and the most common areas affected are the back, head and neck, abdomen and extremeties.

Myofascial pain syndrome (MPS) may be considered a localized form of fibromyalgia in the head and neck. There are three diagnostic criteria:

the presence of painful, firm bands of muscle or tendons, termed trigger points;
pain complaints that follow known patterns of referral of trigger points, and
reproducible pain complaints with trigger points.

Collagen diseases such as systemic lupus erythematosis, Sjogrens syndrome, scleroderma and arthritis also cause muscular pain in the head and neck. Lupus is characterized by a butterfly rash of the face, fever, rheumatoid arthitis and pleural and abdominal pain. Laboratory studies reveal a high sedimentation rate, hypochromic anemia, a positive ANA test and a false-positive VDRL. Scleroderma is characterized by gradual onset of muscle and joint pain leading to a systemic sclerosis with anorexia, dyspnea and diminished sweating. Fever, skin lesions and limited jaw and chest expansion are seen.

Sjogren's syndrome is characterized by dryness of the mouth, eye and skin and oftentimes, muscle and joint pain. Rheumatoid arthritis is a chronic inflammation of the synovial membrane with pain in the muscles and joints. Numerous joints in the body are usually affected, and pain usually decreases with use. Fatigue, fever, muscle pain, night sweats and sometimes weight loss are seen. Studies show the presence of rheumatoid factor, and increased sedimentation rate and antinuclear antibodies.

The treatment of myofascial pain is divided into four phases. Phase one treatment is initiated upon diagnosis, and consists of educating the patient on muscle fatigue and spasm as the cause of pain and dysfunction. It helps to explain referred pain. The avoidance of clenching and grinding is emphasized, and a soft diet is instituted. Nonsteroidal antiinflammatory agents are prescribed, with or without a muscle relaxant. The most commonly used agents are valium and ibuprofen. One half of patients will obtain significant relief in 2-4 weeks. Phase II therapy is initiated if phase I treatment fails. Medications are continued, but a bite appliance (splint) is added. This helps prevent muscle overuse, including bruxism. The appliance is usually worn at night, but can also be worn during the day if necessary. Care should be taken to instruct the patient not to wear the appliance at all times, as the posterior teeth may become displaced. An additional 25% of patients will receive relief with this therapy. Once relief is obtained, the medications are discontinued.

If the patient remains asymptomatic, the appliance is discontinued. If symptoms return, the appliance may be resumed at night, and its use continued as long as necessary. If phase II therapy alone fails, physical therapy of the muscle groups, including ultrasonic therapy, electrogalvanic stimulation or biofeedback are added. No one form of treatment is superior. Another 15% of patients will find relief within four weeks. If phase III therapy fails, psychological counseling is advised to identify stresses, and patients are referred to a TMJ center. TMJ centers employ a multidisciplinary approach, including psychological counseling and trigger point injections, for treatment.

Joint disorders are the second most common cause of persistent head and neck pain. Included are internal derangements, degenerative joint disease and inflammation of the joint space (capsulitis). The greatest difficulty facing the clinician is distinguishing these disorders from those involving the muscles, since the presentations are often similar. Those with TMJ arthropathy often present with the additional finding of clicking or popping on opening or closing of the jaw. Oftentimes, a history of lock jaw can be elicited. Sometimes, the chief complaint is not a pop, but an occlusal instability associated with locking. These signs are highly suggestive of a joint disorder.

The most common TMJ arthropathy is the internal derangement, which is characterized by a progressive anterior disc displacement. It is often associated with a capsulitis, making pain a common feature. On physical exam, a popping is felt and heard, with associated pain.

The most common derangement is anteromedial, and the degree of derangement generally correlates with symptoms. Donlon divided derangements based on findings of history and physical exam. Myofascial pain is associated with pain over the temporomandibular joint without a palpable or audible click. A type IA derangement is found with a popping over the joint without associated pain. It is seen in over 50% of normal subjects. A type IB derangement is popping of the joint associated with pain. The popping is due to the noise the condyle makes as it moves under the anteriorly displaced disc. The pain is due to the stretching and subsequent inflammation of the retrodisc pad.

The type II derangement is similar to a type IB derangement, but a history of lock jaw can be elicited. There are two types of lock jaw. The closed lock is due to the inability of the condyle to slide under the anteriorly displaced disc. The open lock is due to the inability of the condyle to slide back over the disc into its normal position. A type III derangement is a persistent lock, usually closed. Hence, there is usually no associated click or pop on physical exam. Of note, these symptoms are usually progressive. The patient often gives a history of having passed through each type of derangement.

Early treatment of the internal derangement is imperative, as progression of disease leads to a less favorable prognosis. Therapy for type I and II derangements is similar to that for myofascial disorders. NSAIDs and muscle relaxers (valium) are prescribed as is the instruction of a soft diet and jaw rest. Failure of these methods requires the addition of a splint to attempt the repositioning of the condyle. The purpose is to reposition the condyle into a more favorable position related to the disc. Clicking is usually not eliminated, but it may be reduced to a soft pop with reduced pain. If repositioning with a splint fails, arthoscopic or open surgical repair is recommended. The purpose of these procedures is to surgically remove adhesions and to reposition the disc into a favorable position. A type III derangement requires aggressive therapy. The joint is unlocked, usually under anesthesia. Physical therapy and an anterior bite plate is used. If no improvement results after 3 weeks of therapy, TMJ surgery is undertaken to reposition or repair the disc.

Congenital and developmental anomalies of the temporomandibular joint, although relatively rare, are important to identify early to reestablish normal midface growth centers. The more common entities include condylar agenesis, condylar hypoplasia, condylar hyperplasia and hemifacial microsomia.

Condylar agenesis is the absence of all or portions of the coronoid process, condylar process, ramus and mandibular body. Other first and second arch abnormalities are commonly seen. Early treatment is indicated to limit the degree of deformity, with the primary objective being to re-establish the condylar growth center. This is best done with a costochondral graft with or without orthodontic surgery and facial plastic augmentation.

Condylar hypoplasia may be congenital, but is usually the result of trauma or infection. The most common facial deformity is shortness of the mandible with deviation of the chin towards the affected side. Treatment of the child involves the placement of a costochondral graft. In the adult, treatment involves either shortening of the normal side or lengthening of the involved side. Both result in an acceptable cosmetic and functional result. Orthodontic therapy is necessary in all cases to establish proper occlusion.

Condylar hyperplasia is an idiopathic disease characterized by a progressive, unilateral overgrowth of the mandible. The chin is deviated towards the unaffected side. Presentation is common in the second decade. Radiographic findings are usually a normal condyle but an elongated neck. Treatment depends on whether the condyle is still growing. It growth is occurring, condylectomy is the treatment. If growth has ceased, orthognathic surgery is performed.

Traumatic injuries to the condyle are common. The diagnosis of a condylar fracture is usually made easily by physical examination and radiographic studies. A unilateral condylar or subcondylar fracture results in deviation of the jaw towards the site of fracture with opening. Minimally displaced fractures are usually treated with intermaxillary fixation with early mobilization. Displaced fractures or those that interfere with function may have to be treated with open reduction with internal fixation and intermaxillary fixation. Bilateral fractures frequently present with an anterior open bite and are usually treated with IMF and ORIF. In children IMF is the treatment of choice for severely displaced fractures, along with early mobilization. Repositioning of the condylar head may be necessary to reestablish normal midface growth.

Dislocation of the jaw is either acute or chronic. An acute dislocation results when the mandible is fixed in an open position with only the posterior teeth in contact. Treatment is reduction, usually supplemented by IV sedation, although general anesthesia may be required. Chronic recurrent dislocation is usually due to abnormally lax ligaments. Treatment is usually undertaken by injecting sclerosing agents into the joint capsule to produce a scarring and contracture of the ligaments. A capsulorrhaphy may be performed, whereby the ligaments are shortened surgically. If the cause of the chronic dislocation is an abnormally tense or shortened lateral pterygoid muscle, a myotomy is performed.

Ankylosis of the TMJ is an obliteration of the joint space with abnormal bony morphology. It is important to distinguish true ankylosis from false ankylosis, which is an extracapsular condition resulting in an enlarged coronoid process, zygomatic arch fracture or scarring from surgery. In general, severe ankylosis is treated with a prosthetic condyle. Three principles are imperative. First, the new joint should be established at the highest possible point on the ramus to maintain maximal mandibular height. Second, an interpositional material is placed to avoid fusion. Third, aggressive, long term physical therapy is important. In the child, a costochondral graft is preferred over a prosthetic joint to attempt to replace the condylar growth center.

Arthritic changes are the most frequent pathologic conditions affecting the temporomandibular joint, but most are asymptomatic. All types occur, but degenerative and rheumatoid arthritis are the most common.

Rheumatoid arthritis is usually seen in other joints prior to TMJ involvement. With progression, bilateral TMJ tenderness and swelling are seen. In early stages, there are few radiographic changes, but as the disease advances the joint space becomes progressively narrower. In end stage rheumatoid arthritis of the TMJ this joint space obliteration results in an anterior open bite. In juvenile rheumatoid arthritis with TMJ involvement, end stage disease can result in destruction of the condylar growth plate.

Treatment of rheumatoid arthritis of the TMJ is similar to other joints. Nonsteroidal antiflammatory medications are used during the acute phase along with jaw exercises once the pain subsides. In severe, chronic cases, drugs such as penicillamine and gold are used. Surgery is limited to severe, refractory ankylosis, as discussed above.

Degenerative arthritis can be either primary or secondary. Primary disease is seen in old people and is a disease of wear and tear. Patients are usually asymptomatic, and when symptomatic, the complaints are usually mild. Secondary dejenerative arthritis occurs secondary to trauma or chronic bruxism. It occurs in younger people and the symptoms are much more severe. Radiographic findings consist of a primarily unilateral lipping of the joint with osteophyte formation and erosion of the articular surface of the condyle. Again, in children, damage to the growth plate must be suspected.

Treatment of degenerative arthritis is similar to that of myofascial disorders and early internal derangements. NSAIDs and muscle relaxers with a soft diet are the primary treatment. Bite appliances are added as necessary. When conservative medical management fails to improve symptoms after a 3-6 month trial, surgery is considered. Surgical intervation includes removal of any surgical capsular abnormality, including osteophytes, until the joint space is smooth. A condylar shave is when the entire cortical plate is removed. It should be avoided if possible, as resorption of the condyle is a known complication.

Neoplasms of the TMJ are uncommon. The most common tumors are benign, and include chondromas, osteomas and osteochondromas. Rarely, fibrous dysplasia, giant cell reparative granuloma and chondroblastoma are seen. Very infrequently malignant tumors such as fibrosarcoma and chondrosarcoma are seen.

Surgery is the treatment of choice for neoplasms of the TMJ. Radiation therapy is generally ineffective.

Surgery of the Temporomandibular Joint

Surgery of the temporomandibular joint is an effective treatment for structural disorders, but the high frequency of psychosocial contributing factors and the availability of medical therapy necessitates careful patient selection. Numerous studies and guidelines exist, many of which are contradictory. At the University of Minnesota, less than 10% of patients enrolled in the chronic Craniofacial Pain Clinic have required surgery, and in general, less than 1% of all patients with symptomatic TMJ disorders require surgical intervention.

There are several general surgical indications. Documented refractory internal derangements are the most common indication. Pain and dysfunction of such magnitude as to constitute a disability to the patient is an indication, but thorough documentation and informed written and verbal consent are an absolute necessity. Prior unsuccessful medical management is also an indication. It is imperative to understand despite careful selection, psychosocial factors are believed to play a large factor in some patients.

There are five general surgical procedures:

disc repair,
menisectomy,
menisectomy with implant,
bone reduction procedures, and
arthroscopy.

Disc repair procedures are recommended for minimal morphologic changes. The disc's posterior attachment is incised and the anteriorly displaced disc is repositioned posteriorly over the condyle in a more normal anatomic position. If a large articular eminence exists, smoother function may be obtained by excising a portion of the eminance or the condyle. Approximately 90% of patients achieve reduced symptoms.

Menisectomy is the removal of the disc. It is recommended when severe changes in disc morphology occur. A temporary implant may be designed to maintain disc space. About 85% of patients receive relief, but 15% require further surgery for refractory pain. A long term risk is osseous changes of the joint space.

Menisectomy with implantation involve removal of the disc with placement of a permanent interpositional implant. The implant stabilizes the joint space allowing smoother function and less risk of osseous changes. Silastic implants are most common, although proplast, temporalis fascia and auricular cartilage are also used. Some choose to remove the implant after several weeks, as scar tissue forms around the implant and acts in much the same manner as a disc. Several animal models have shown failure of these implants are associated with a significant foreign body reaction involving giant cells and other inflammatory infiltrates.

Bone reduction procedures preserve the disc through a high conylotomy or condylectomy. These procedures are designed to increase joint disc space. A condylotomy involves performing an osteomy on the neck with repositioning of the condyle. A condylectomy involves an extended condylotomy with removal of bone.

Arthroscopy is the endoscopic examination of the joint space. It is used for both diagnosis and treatment. Adhesions and loose bodies are the most common indications and findings for arthroscopic treatment of the temporomandibular joint. Advancements in techniques have allowed arthroscopy to be employed in several internal derangement procedures, including some disc procedures.

Most studies report minimal morbidity associated with TMJ arthroscopy. The most common complications include bleeding, infection and damage to the facial nerve.

Complications of temporomandibular surgery are difficult to predict. Psychosocial factors play a large role, and depression is seen. Failure to improve symptoms is the most common complaint. Infection, capsulitis, facial nerve injury, degenerative joint disease and anterior open bite are findings seen on physical exam.

Radiology

Plain films, computed tomography, magnetic resonance imaging and arthrography are the studies utilized in the TMJ. MRI is noninvasive and is the best technique for evaluating disc morphology and position. CT is useful for evaluation of bony deformaties. Plain films with or without arthrography are occasionally used. In general, fibromyalgia requires no imaging study. Type I and II internal derangements require MRI, whereas ankylosis and other bony disorders are best examined by computed tomography. Of note arthroscopy is often employed as well.

Editor's Comments:

Physical findings which support an initial diagnosis of temporomandibular arthralgia include:

complete absence of molar teeth in any one quadrant,
deviation of the jaw to the painful side on wide opening,
reproducibility of the pain by pressure below the ear forward in the direction of the mandibular condyle,
reproducibility of the pain by pressure from within the membraneous ear canal forward in the direction of the mandibular condyle, typically by reversing a laryngeal mirror and pressing with the round end of the handle in the ear canal, and
reproducibility of the patient's complaint of "ear pain" by inserting two tongueblades between the opposite molars and instructing the patient to bite down hard on the tongue blades

Once the patient has come to realize that the pain is arising from the joint and not the ear, it is easier to persuade him/her to consult his dentist for occlusal equillibration, or perhaps even an occlusal splint.

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The Parotid Region of the Face

The parotid region is actually part of the neck but it extends into the facial region as well. It also must be studied before the infratemporal region can be examined. We will examine the parotid region from superficial to deep pointing out the gland itself and the structures running through it.

The parotid gland is a superficial structure located in the upper neck above the posterior belly of the digastric muscle. It is a salivary gland that has a large duct (pd) which crosses the masseter muscle to pierce the buccinator muscle opposite the upper 2nd molar tooth. The duct can frequently be rolled between the finger and the masseter muscle. The skin overlying the lower pole of the gland is supplied by the greater auricular nerve (ga), a branch of the cervical plexus. You have already identified the branches of the facial nerve appearing at the upper and anterior edges of the gland (yellow).
If the parotid gland is carefully removed, you can identify the structures located within it. The first plane is the venous plane and consists of the retromandibular vein (rm) and its tributaries and branches: st--superficial temporal rm--retromandibular vein m--maxillary vein ad--anterior division f--facial cf--common facial pd--posterior division pa--posterior auricular ej--external jugular The common facial vein empties into the internal jugular vein and the external jugular into the subclavian vein near its junction with the internal jugular.
When the venous plane is removed we reach the important nervous plane. The importance of this plane is the presence of the facial (VII) nerve. The facial nerve leaves the skull through the stylomastoid foramen and immediately enters the deep part of the parotid gland where it gives off its branches: posterior auricular (pa) motor branch to posterior belly of digastric (db) temporal branch (t) zygomatic branch (z) buccal branches (b) mandibular branch (m) cervical branch (c)
Deep to the nerves lies the arterial plane which includes terminal parts of the external carotid artery and its branches: external carotid artery (EC) occipital artery (oc) maxillary artery (m) transverse facial artery (tf) superficial temporal artery
The deepest part of the parotid region is the parotid bed and houses the deep part of the gland which fills the small space between the neck of the condyle of the mandible (nc) and the mastoid process (m). Other structures forming the floor of this space are the : styloid process (sp) stylohyoid muscle (sh) stylopharyngeus muscle (sph) posterior belly of the digastric muscle (pbd) The gland becomes infected and swollen in mumps. If you have had the mumps, you will realize just how difficult it is to open your mouth. Now, you can see why this is so. When you open the mouth, you narrow the parotid bed space and compress the deep parotid gland between the neck of the condyle and the mastoid process.

The Infratemporal Fossa and Muscles of Mastication

The infratemporal fossa is a small space between the ramus of the mandible and the lateral pterygoid plate of the sphenoid. On a skull, it is big enough for maybe 1 1/2 fingers but it has many things in it. Following is a tabulation of the infratemporal fossa and all of its contents.

The lateral wall of the infratemporal fossa is noted in the 1st image and consists of the

ramus (4)
- coronoid process (1)
- head of condyle (2)
- neck of condyle (3)
body (5)
angle (6)

Medial wall:
lateral pterygoid plate (1)
Roof;
greater wing of sphenoid (3)
includes foramen ovale & foramen
spinosum
Posteriorly:
styloid process (4)

There are four muscles of mastication on each side that control the movement of the mandible:

masseter
medial pterygoid
lateral pterygoid
temporalis

The lateral pterygoid is the main muscle that opens the mouth. It is helped from gravity and a couple of neck muscles. It opens the jaw by pulling forward on the neck of the mandible and causing the jaw to drop.

The artery entering the infratemporal fossa is the maxillary branch of the external carotid artery. As can be seen, it has many branches (11 in all). You will probably not be responsible for all of them but I have included them all for completeness.

Maxillary artery

deep auricular (da)
anterior tympanic (at)
middle meningeal (mm)
accessory middle meningeal (amm)
inferior alveolar (ia)
buccal (b)
deep temporal (dt)
posterior superior alveolar (psa)
descending palatine (dp)
infraorbital (io)
sphenopalatine (sp)

External carotid artery (ec)

occipital (oc)
transverse facial (tf)
superficial temporal (st)

The sphenopalatine and descending palatine arteries pass through a small space between the pterygoid process of the sphenoid and the maxilla, the pterygomaxillary fissure.

The mandibular nerve (V3) is the nerve of the infratemporal fossa and is responsible for supplying the muscles of mastication plus two tensor muscles: 1) tensor palati and 2) tensor tympani. The branches are as follows:

deep temporal (dt)
auriculotemporal (at)
inferior alveolar (ia)
- nerve to the mylohyoid (nmh)
lingual (l)
buccal (b)
branches to lateral pterygoid (not labeled)

Not shown:

meningeal branch
nerve to masseter

The Temporomandibular Joint (TMJ)

The temporomandibular joint (tmj) is a synovial type joint separated by an interarticular disc. The disc splits the joint into two separate joints. The upper joint (ujc) is between the mandibular (articular) fossa of the temporal bone and the articular disk and provides a sliding motion when the lateral pterygoid contracts and pulls the condyle and disc forward.

The lower joint (ljc) is between the articular disc and the head of the condyle of the mandible. The action here is a hinge-like action, in which the mandible drops, thereby opening the mouth.

When dentition or muscle action is not in proper alignment, the joint can be secondarily affected and pain can ensue. This is TMJ disease and requires dental specialists to correct the problem.

Table of Muscles

Muscle	Origin	Insertion	Action	Nerve Supply
masseter	zygomatic arch	ramus & angle of mandible	closes mouth	muscular branch (V3)
medial pterygoid	medial surface of lateral pterygoid plate and maxillary tuberosity	medial surface of ramus and angle of mandible	closes mouth and helps protrude mandible	muscular branch (V3)
lateral pterygoid	upper head: greater wing of sphenoid lower head: lateral surface of lateral pterygoid plate	upper head: articular disc lower head: neck of condyle	open and protrudes mandible, moves mandible side to side	muscular branch (V3)
temporalis	temporal fossa	coronoid process and anterior border of ramus	closes and retracts mandible	muscular branch (V3)

Summary of Items in This Lesson

Bones
Mandible
body
angle
ramus
condyle
head
neck
coronoid process
mental foramen

Temporal bone
Mastoid process
styloid process
stylomastoid foramen
mandibular (or articular) fossa
Temporomandibular joint
articular disc
Sphenoid bone
greater wing
foramen ovale
foramen spinosum
pterygoid process
lateral pterygoid plate
Pterygomaxillary fissure
Posterior surface of maxilla
posterior superior alevolar foramina

Muscles

Masseter
Medial pterygoid
Lateral pterygoid
upper belly
lower belly
Temporalis

Nerves

Mandibular division of trigeminal (V3)
auriculotemporal
deep temporal
inferior alveolar
nerve to mylohyoid
lingual
chorda tympani
buccal
muscular branches
muscles of mastication
tensor palati
tensor tympani

Nerves (contd.)

Facial (VII)
posterior auricular
tympanic
zygomatic
buccal
mandibular
cervical
branch to posterior belly of the digastric

Arteries

external carotid
occipital
maxillary
inferior alveolar
middle meningeal
accessory middle meningeal (if present)
deep temporal
buccal
posterior superior alveolar branches
descending palatine
sphenopalatine
infraorbital
transverse facial
superficial temporal

Veins

superficial temporal
maxillary
retromandibular
anterior division
facial
common facial
posterior division
posterior auricular
external jugular

Viscera

parotid gland
parotid duct

TMJ/ Myofacial Pain
COMPUTERIZED DIAGNOSTICS: The Key to Success

WHAT IS "TMJ'?

According to the National Institutes of Health, Temporomandibular Disorders refer to a collection of medical and dental conditions affecting the temporomandibular joint and/or the muscles of mastication (chewing muscles), as well as related tissue components.

"The TMJs are the two joints in the front of the ears that attach the lower jaw (mandible) to the skull (fossa). Not only do the jaw joints rotate as other ball-and-socket joints, they translate (move down and forward). The disc (articular disc) is a thin piece of tissue acting as a buffer between the skull and the condyle (top of the mandible).

When intact, they are the only joints in the human body that work together as a unit. These joints, often taken for granted, allow us to perform functions as opening and closing the mouth, chewing, swallowing, breathing, kissing, talking, etc. Problems that can occur with the temporomandibular joint are arthritis, trauma, tumors, tearing or dislocation of the disc. The TMJs and the mandibular complex are able to function and move by means of innervated muscle, tissue, and ligaments that are the connecting components between the lower jaw (the mandible) and the skull (cranium). There often can be accompanying muscle spasms that effect temporomandibular diseases/disorders which often are diagnosed as Fibromyalgia or Myofacial Pain Dysfunction. You may experience joint problems, muscle problems or both.

Numerous Signs and Symptoms
"TMJ" as we know it presents with numerous signs and symptoms which include: a clicking or popping jaw and mild discomfort to complete jaw dysfunction and severe debilitating pain. Many can experience a varying combination of these symptoms with varying degrees of discomfort. Many discover that these symptoms may be transient and go away on there own with or without treatment. However, for many others, it can be the beginning of a long, agonizing and frustrating life where lives are disrupted, dreams shattered, families torn apart and people left bankrupt, desperate and without hope. If you have TMJ, you may have spent years of your life and thousands of dollars being referred from one doctor to another hoping for relief. Doctors may have told you that you are crazy or need to better handle your stress. They may have told you that you don't have pain. They may even have abandoned you, saying there is nothing more to be done for you...that is, after you have spent thousands or hundreds of thousands of dollars on treatments.

If this sounds familiar, you are not alone. You are not crazy and you are not to blame if you haven't gotten better. It is possible that you have received one or many of the over 49 treatments being recommended to TMJ patients in this country, most being sold on the basis of the doctor's preference, not scientific evidence of safety or effectiveness. The treatment may, in fact, be making you worse. You may feel caught in a quagmire. Your personal experience may be that there is a great deal of disagreement among professionals about most aspects of temporomandibular joint diseases/disorders.

SYMPTOMS

The symptoms most commonly cited are as follows:

Facial pain
Jaw joint pain
Back, Neck, cervical pain
Postural problems (forward head posture)
Pain in the joint(s) or face when opening or closing the mouth, yawning, or chewing
Headaches (tension type)
Pain in the muscles surrounding the temporomandibular joints
Pain in the occipital (back), temporal (side), frontal (front), or infra-orbital (below the eyes) portions of the head
Pain behind the eyes
Swelling on the side of the face and/or mouth
A bite that feels uncomfortable, "off," or as if it is continually changing
Clenching/bruxing
Tender sensitive teeth
A limited opening or inability to open the mouth comfortably
Deviation of the jaw to one side
The jaw locking open or closed
Ringing in the ears, ear pain, diminished hearing, and/ or hyperaccusis
Sinus like symptoms
Dizziness or vertigo
Visual Disturbances
Tingling in fingers and hands
Insomnia - difficulty sleeping

This list of subjective symptoms is by no means exhaustive, but does provide a good idea of the nature of the complaints that are often made by those suffering from TMD.

Diagnostic Classification
The NIH Technology Assessment Conference Statement concludes, "there are significant problems with present diagnostic classifications of TMD, because these classifications appear to be based on signs and symptoms rather than on etiology." They further state that, "...scientifically based guidelines for diagnosis ... are still unavailable."

"One of the most difficult and controversial diagnoses the practicing dentist must make is that of the temporomandibular joint dysfunction syndrome (MPD). Controversy still abounds in our literature and at professional meetings even though almost all involved therapists agree that head and neck muscles are affected in the syndromes. The champions of each concept of etiology tend to ignore or belittle the conflicting concepts as though there can be only one cause of TMJ-MPD problems."

- Parker E. Mahan, DDS, PhD, Professor and Chairman
Department of Basic Dental Sciences, University of Florida, Gainesville, Florida

The dental community usually diagnoses TMJ based on several things, including range of motion tests, listening for sounds in the joints, examining the teeth, and palpation of the jaw joints as well as the muscles of the face, and head. Typically the dentist will ask for information about your pain and other symptoms, injuries, oral habits, and previous medical and dental treatment.

HOW MANY PEOPLE HAVE "TMJ"? WHO GETS IT?
According to the National Institutes of Health, over ten million Americans suffer from TMJ Diseases/Disorders. This is the most conservative estimate we have seen.

Both males and females can get TMJ diseases/disorders. However, 90% of those seeking treatment for TMJ are women, most between puberty and menopause. Recent research has focused attention on the relationship between sex hormones and pain. A study conducted by Dr. Linda LeResche, University of Washington in Seattle, demonstrated that women on hormone replacement therapy were 77% more likely to seek treatment for jaw pain than those not undergoing such treatment. Also, women on oral contraceptive therapy were 19% more likely to seek treatment. Evidence is emerging in support of a biological explanation for why there are more women suffering from TMJ pain.

A study done by Dr. Peter Waite, University of Alabama at Birmingham "demonstrates a high incidence of TMJ dysfunction among Mitral Valve Prolapse patients and leads to a suspicion of a common connective tissue disorder." In an unrelated survey conducted by the Society for Mitral Valve Prolapse Syndrome, of 240 patients surveyed 51% had also been diagnosed with TMJ.

A recent study conducted by Dr. J.C. Turp found that among a great percentage of TMJ patients the pain distribution was more widespread than commonly assumed. "Evidence suggests a significant overlap between temporomandibular disorder states and pain conditions in other parts of the body".

Consult Your Medical Doctor
We recommend that you first consult with a medical doctor to rule out any disease that may be causing your symptoms and is treated by medical practitioners. If they are unable to find a reason for your problem, and you are referred to a dentist for a TMJ evaluation, we encourage you to then obtain multiple INDEPENDENT opinions on your condition.

Get an Independent Opinion
To be a truly independent opinion, the medical/dental professional can not be associated with or working with the medical/dental professional from whom you have already received an opinion. Many TMJ patients seek further opinions outside of their geographical area, without the referral of their original medical/dental professional.

Educate Yourself and Others
With the increase of managed care (HMOs), where a primary care physician is your health care gatekeeper it is mandatory that you, the patient, become your own well-informed advocate. You will also need to educate your primary care physician and all others you encounter within the system about TMJ.

As the Washington Post states in their Health News section on May 7, 1996, this is critical for " ...medical science is so uncertain about how to treat jaw pain because the disorder has not been accurately diagnosed or described - and no one is sure whether it should be treated by doctors or dentists, or both." For additional information on treatment modalities and problems see our section on Treatments.

Musculoskeletal Dysfunction (MSD) of the Head and Neck Resulting in Temporomandibular (Jaw) Joint Dysfunction ("TMJ")

(Some portions of the following section contains excerpts of writings from Dr. James Garry, who is an expert in treating musculoskeletal dysfunctions of the head, neck and temporomandibular joint dysfunction as well as air-way obstruction/ sleep apnea problems).

Patients suffering facial pain, headaches, neck aches, shoulder, and/ or back pain often have to learn to live with the pain.

Some patients have subjective hearing loss, ringing of the ears, dizziness, pain in the ear, a feeling of fullness or pressure in the ears, clicking/ popping of the jaw joints and eye pain. The mouth, teeth and throat may also be affected. When competent clinicians cannot find an organic basis for these symptoms, they often suggest it might be psychogenic.

There is a classification of disease known as Musculoskeletal Dysfunction of the head and neck (MSD). MSD seems totally unrelated to symptoms such as back pain or ear disorders. Yet, correction of this condition may alleviate many medical symptoms; acute or chronic diseases of the ear, nose, throat, head, neck, shoulder and back. The syndrome is medically as well as dentally related.

TMJ/ MSD is a dysfunction of a group of associated muscles, ligaments, nerves and supportive structures that are associated with the temporomandibular joint. Unfortunately, TMJ/ TMD is one of the most misdiagnosed of the medical/ dental conditions. There are two aspects that contributes to this sad phenomenon of misdiagnosis.

First, few doctors including physicians, ENT specialists, dentists, chiropractors, osteopaths, etc. have a comprehensive understanding and perspective in the diagnosis and treatment of TMJ/ MSD.

Secondly, these disorders have many overlapping symptoms which mimic many other conditions such as neurological disorders, ringing and fullness in the ear, headaches, etc.

Misdiagnosis is the rule rather than the exception with MSD. Patients wander from specialist to specialist, depending on the type of pain and problems they experience. Symptoms focusing on ear, sinuses, or swallowing problems are referred to the Otolaryngologist. Limitations of jaw movement are referred to the Orthopedist. Persistent head pains are referred to the Neurologist, etc.

As the wanderers are told and retold that there seems to be no organic basis for their pain, that the cause is psychogenic, their anxiety mounts. When physical findings remain obstinately in abeyance, patients may begin to suspect a brain tumor, turn to drugs to alleviate their symptoms, or on rare occasions, even contemplate suicide.

ANATOMY OF TEMPOROMANDIBULAR JOINT:

The Temporomandibular Joint is the joint connecting the jaw (mandible) to the skull (temporal bone).

The two bones are held together and function via a complex group of muscles, ligaments and other soft tissue. The temporal bone has a concavity call the glenoid fossa in which the head of the jawbone (the condyle)sits. A cartilage disc call the articular disc separates the two bones. The articular disc slides in conjunction with the mandible to provide smooth quiet movement and acts as a cushion against heavy forces generated by the strong jaw muscles. The right and left TMJ joints do not act as a separate joints, but must move in coordination with one another.

The TMJ joints are considered the most complex joints in the human body because they must provide for rotational movements, sliding movements and an infinite range of combined movements and functions, unlike any other joint in the body.

The lower jaw (Mandible) has a relationship to the upper jaw (Maxilla). If this relationship is altered, the muscles of mastication (chewing muscles) go into spasm. This causes the muscles that have the same nerve intervention to also go into spasm. The resulting stresses may radiate throughout the head, neck, and even involve the back. The pain may be constant or intermittent, lasting minutes, hours, days, or even years. Many patients describe the pain as a migraine headache. Eventually a patient may demonstrate clicking, grating, snapping, or popping sounds in the joint.

MECHANICS OF TEMPOROMANDIBULAR JOINT DYSFUNCTION:

The lower jaw may be over closed (too close to the upper jaw), and /or distally displaced (too far back in the joint or socket). Also, the lower jaw may deviate to one side due to interfering tooth cusps (points on the chewing surfaces of teeth that do not meet properly with the opposing teeth).

The cause is multifaceted, i.e., loss of teeth, poor alignment or natural wear of teeth, grinding or clenching of the teeth day and night, poor tongue position, a muscle imbalance in the tongue and the facial muscles, chronic mouth breathing, osteoarthritis, rheumatoid arthritis, trauma, etc.

To determine if an improper relationship exists between upper arch and the lower jaw, it is necessary to relax the muscles of mastication (chewing muscles), then close the relaxed lower jaw on a trajectory that is not strained. In other words, the mouth closes where the muscles are most comfortable.

To relax the muscles of mastication, a gentle pulsating stimulus is applied to the skin for approximately one hours. Multi-channel electromyography (EMG) is used to verify the degree of muscular relaxation.

MSD is not a rare condition. Every patient has some degree of Musculoskeletal dysfunction. It is when symptoms are manifested that people seek help. Many patients tend to clench and/or grind their teeth in response to unconscious stress, creating muscular dysfunction. This usually occurs during sleep, but it may also occur during a stressful daily experience. Resolution of unconscious stress which cause symptoms indicated on the Screening questionnaire may require stress counseling. Subconscious stress must be controlled for successful resolution of clenching and /or grinding of teeth.

POSTURE AND AIRWAY

Posture has an effect on the relationship of the lower jaw to the cranium and can result in a malocclusion (improper bite). If body symmetry is not within normal limits, physical therapy may be necessary to correct body symmetry during treatment.

Airway obstruction must be cleared as it will result in constant mouth breathing. Allergy is a primary cause of chronic mouth breathing. If nasal obstruction is evident, consultation with an allergist and/or Otolaryngologist will be recommended during treatment. All chronic mouth breathers develop an improper bite (malocclusion).

INITIAL TREATMENT FOR TMJ:

Three approaches or a combination thereof, may be recommended as initial therapy:

1. Occlusal correction or coronoplasty (reshaping teeth to remove interferences that cause abnormal jaw displacement).

2. Construct an orthotic to orthopedically align the lower jaw to the cranium in three dimensions providing there is an over closure. If symptoms subside after wearing the appliance for three months, crowns may be recommended to maintain the orthopedic position established by the orthotic. Orthododontia may be recommended to avoid crowns. Possibly a combination of orthodontia and crowns will be recommended. When posterior (back) teeth are missing, dentures and /or partials may be recommended. For more details, see OUR TREATMENT PROTOCOL

3. Surgery is the last and least recommended when irreversible damage has occurred in the joints and is beyond natures healing capacity.

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