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What are the temporomandibular joints (TMJ)?
The temporomandibular joints (TMJ) are the 2 joints that connect your lower jaw to your skull. More specifically, they are the joints that slide and rotate in front of each ear, and consist of the mandible (the lower jaw) and the temporal bone (the side and base of the skull). The TMJs are among the most complex joints in the body. These joints, along with several muscles, allow the mandible to move up and down, side to side, and forward and back. When the mandible and the joints are properly aligned, smooth muscle actions, such as chewing, talking, yawning, and swallowing, can take place. When these structures (muscles, ligaments, disk, jaw bone, temporal bone) are not aligned, nor synchronized in movement, several problems may occur.
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What is temporomandibular disorder (TMD)?
Temporomandibular disorders (TMD) are disorders of the jaw muscles, temporomandibular joints, and the nerves associated with chronic facial pain. Any problem that prevents the complex system of muscles, bones, and joints from working together in harmony may result in temporomandibular disorder.
The National Institute of Dental and Craniofacial Research classifies TMD by the following:
Myofascial pain. This is the most common form of TMD. It results in discomfort or pain in the fascia (connective tissue covering the muscles) and muscles that control jaw, neck and shoulder function.
Internal derangement of the joint. This means a dislocated jaw or displaced disk, (cushion of cartilage between the head of the jaw bone and the skull), or injury to the condyle (the rounded end of the jaw bone that articulates with the temporal skull bone).
Degenerative joint disease. This includes osteoarthritis or rheumatoid arthritis in the jaw joint.
You can have one or more of these conditions at the same time.
What causes TMD?
In many cases, the actual cause of this disorder may not be clear. Sometimes the main cause is excessive strain on the jaw joints and the muscle group that controls chewing, swallowing, and speech. This strain may be a result of bruxism. This is the habitual, involuntary clenching or grinding of the teeth. But trauma to the jaw, the head, or the neck may cause TMD. Arthritis and displacement of the jaw joint disks can also cause TMD pain. In other cases, another painful medical condition such as fibromyalgia or irritable bowel syndrome may overlap with or worsen the pain of TMD. A recent study by the National Institute of Dental and Craniofacial Research identified clinical, psychological, sensory, genetic, and nervous system factors that may put a person at higher risk of developing chronic TMD.
What are the signs and symptoms of TMD?
The following are the most common signs and symptoms of TMD:
Jaw discomfort or soreness (often most prevalent in the morning or late afternoon)
Headaches
Pain spreading behind the eyes, in the face, shoulder, neck, and/or back
Earaches or ringing in the ears (not caused by an infection of the inner ear canal)
Clicking or popping of the jaw
Locking of the jaw
Limited mouth motions
Clenching or grinding of the teeth
Dizziness
Sensitivity of the teeth without the presence of an oral health disease
Numbness or tingling sensation in the fingers
A change in the way the upper and lower teeth fit together
The symptoms of TMD may look like other conditions or medical problems. See a dentist or your doctor for a diagnosis.
What are the treatments for TMD?
Your healthcare provider will figure out the best treatment based on:
How old you are
Your overall health and medical history
How well you can handle specific medicines, procedures, or therapies
How long the condition is expected to last
Your opinion or preference
Treatment may include:
Resting the temporomandibular joint (TMJ)
Medicine or pain relievers
Relaxation techniques and stress management
Behavior changes (to reduce or stop teeth clenching)
Physical therapy
An orthopedic appliance or mouthguard worn in the mouth (to reduce teeth grinding)
Posture training
Diet changes (to rest the jaw muscles)
Ice and hot packs
Surgery
Medically Reviewed by:Ivan F. Stein, DDS
There are a number of treatment options available to correct TMJ disorder. Your particular treatment should be determined through consultation with a dental professional who is highly experienced in temporomandibular joint problems. Ideally, your dentist should have expertise in evaluating jaw-to-bite relationships and experience with proper treatment procedures such as occlusal equilibration and the use of intra-oral appliances.
Treatment Options: Conservative is Key
“Conservative” is the key word when it comes to TMD treatment. Most treatments are simple and can be done at home without the need for surgery. The most severe cases may require treatment with splints, mouth guards, or other traditional forms of TMD therapy like physical therapy.
Regardless of the treatment prescribed for you, it is important that you follow your dentist’s instructions. You should also keep up with routine dental visits so your dentist can regularly monitor your TMJ symptoms.
In addition, the TMJ Association advises patients to keep in mind that there is currently no evidence to suggest that TMD can be prevented. Therefore, caution is advised regarding any treatment(s) presented as providing this benefit.
Traditional Treatment Options
A careful examination of the joints and occlusion is a critical step before a specific treatment is selected. Some specialists have a computer to analyze your bite. Only a small percentage of TMD cases require surgical intervention. If an improper bite is the cause of the TMD, many bite corrections can be achieved with orthodontics, restorations, equilibration or appliance therapy.
Appliance Therapy (Splint or Mouth Guard)
Typically the first line of treatment provided by your dentist will be the use of a splint. The splint is worn to reduce stress on the jaw and to allow the muscles to function optimally and/or to cover the deflective interferences affecting the bite so that the lower jaw can be repositioned into the socket properly. If a splint helps relieve the pain, it is possible that your bite or parafunction was causing the problem.
Many types of splints and appliances may be fabricated by your dentist. The appliance that is best for you will be decided based upon clinical findings, symptoms, and diagnostic tests (X-rays, etc.). Such appliances may help improve your bite while it is in place, thus providing the ability for the lower jaw to fall properly into the temporomandibular joint socket.
Occlusal Equilibration
If your dentist determines that no structural disorder exists in the joint, but that there are deflective interferences on the teeth that are affecting the bite and causing an improper jaw closure, you may undergo occlusal equilibration or your dentist may elect to treat the bite with an appliance.
Many TMJ cases can be corrected with occlusal equilibration, particularly when performed by a dentist experienced in TMD. Occlusal equilibration involves selective reshaping of the biting surfaces of the teeth and is often the best choice for eliminating deflective interferences so that the jaw can close properly. Once the lower jaw is able to close properly into position within the temporomandibular socket, your pain may be relieved immediately. Pain relief is typically achieved when the muscles are able to function properly.
Treating Structural Disorders
If your dentist suspects a structural disorder within the joint itself, further studies may be necessary prior to treatment to ensure that a proper diagnosis is made. The panoramic X-ray is an excellent screening tool though other diagnostic tests may be required.
These include:
- MRI (magnetic resonance imaging) may be used to help your dentist view the soft tissue area surrounding the disc joint.
- CT (computed tomography) scan to evaluate the bony areas of the jaw and hinge joint.
Depending on what these images reveal, your dentist may recommend an intra-oral appliance, orthodontia, or maxillofacial surgery. You may be referred to an oral surgeon or oral and maxillofacial surgeon who will further evaluate and treat your condition.
Surgical Treatment
Typically, surgery is only considered after all other conservative treatment options have been attempted. It is important to know that surgery may not always resolve TMD issues.
All TMJ-related surgery is performed under general anesthesia.
Some of these procedures include:
- Arthrocentesis: During this minor procedure, your surgeon cleanses the joint by inserting needles into the joint area and dispensing sterile fluid. In some cases, the surgeon inserts a scalpel-like instrument inside the joint to remove any tissue adhesions and reposition the disc in the joint hinge.
- Arthroscopy: During this procedure, your surgeon makes an incision at the temple point in front of the ear to reach an endoscope into the surrounding area. The endoscope provides a visual guide so that your surgeon can remove any adhesions, treat inflammation, or reposition the disc.
- Open Joint Surgery: This may be the only option that provides access to deteriorating bony structures, tumors, severe scarring, or chipped bone areas. Depending on the type of problem, your surgeon may use a scalpel to remove or re-sculpt the affected area.
Alternatively, open-joint surgery may be performed. This may be the only option that provides access to deteriorating bony structures, tumors, severe scarring or chipped bone areas. Depending on the type of problem, your surgeon may use a scalpel to remove or re-sculpt the affected area.
Treatment Costs
TMJ treatment costs depend on several factors, including the expertise of the dentist, the location of the dentist, the type of dental insurance you have, and the facility fees for procedures. For example, if occlusal orthotics or a removable appliance is prescribed as part of your TMJ treatment, the cost could be roughly $800 to $3,500.
Depending on the type of medical and dental insurance you have, insurance companies may offer a reimbursement of the total procedure costs.
Alternative Treatments
Alternative medical treatment for TMD is considered less conservative and unnecessary if you initially receive proper diagnosis and treatment.
Alternative treatments include transcutaneous electrical nerve stimulation (TENS), ultrasound, trigger-point injections, and radio wave therapy. TENS and radio wave therapy send low levels of electrical or radio waves of energy to the affected area in order to stimulate blood flow to the joint and surrounding area. However, these options do not treat the causes of TMD and may only provide limited, temporary, symptomatic relief.
Botox
Once reserved for lessening the tell-tale signs of aging, such as annoying wrinkles and frown lines, Botox injections are being used more frequently in dental offices as “off label” treatments for more troublesome maladies such as TMD. Scientific studies have shown that patients who received the injections experienced significant improvements in pain, function, ability to open their mouth, and levels of tenderness to palpation.
Botox is injected into the temporalis, medial pterygoid (deep jaw muscle), and masseter muscles that together move the jaw. Botox blocks nerve signals that cause uncontrollable muscle movements, essentially relaxing the muscles.
Botox injections take only 10 to 15 minutes and remain effective for anywhere between 2 and 6 months. Therefore, like its cosmetic counterpart, Botox TMD treatments must be repeated every few months. If you have TMD and your dentist determines that you are a candidate for this treatment, how often you’ll need to receive Botox injections to relieve symptoms will depend on the severity of your condition.
To achieve a successful outcome, it is important for your dentist to use the correct injection technique as well as follow the appropriate dosage guidelines.
Cost of Botox Treatment
The cost of the Botox treatment will vary based on where you live, where you receive treatment, and the severity of your condition (and therefore how many Botox injections are needed). Botox treatment is usually charged on a per-visit basis.
Most dental insurance companies do not cover Botox treatments because they are “off label,” optional treatments. Therefore, the costs associated with your treatment most likely will be out-of-pocket expenses. However, financing or payment plans may be available.
[updated May 13, 2019]
About the Reviewer
Ivan F. Stein, DDS, is a recognized innovator in neuromuscular and cosmetic dentistry. He has dedicated two decades of his career to researching and treating functional disorders of the jaw and mouth – including temporomandibular joint disorder (TMD) and excessive snoring caused by obstructive sleep apnea (OSA) – as well as full mouth reconstruction.
Dr. Stein earned his Doctor of Dental Surgery degree at prestigious Georgetown University Dental School. He has personally developed a number of successful oral appliances for use in neuromuscular dentistry, including Oravan OSA, an oral appliance for the treatment of obstructive sleep apnea. Dr. Stein was named a Top Dentist in NJ Monthly Magazine and has been invited to appear on ABC and CNBC to discuss dentistry as an art, as well as the safety of dental materials. He is in private practice at Northfield Dental Group, serving patients in and around West Orange, Short Hills and Livingston, New Jersey.
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