Find Freedom from Pain with TMJ Treatments in Lafayette, LA

According to the lay person the TMJ (Temporomandibular Joint) is a term that is often used to identify a multifaceted multi etiologic group of problems that involve both medical as well as dental conditions involving the temporomandibular joint, muscles of mastication, the teeth/occlusion as well as the central nervous system. TMJ is more appropriately called TMD (Temporomandibular Joint Disorder or Dysfunction).

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.

Common problems that can occur with the temporomandibular joint are disc disorders or internal derangments of the disc, disc locations, tearing of the lateral and medial collateral ligaments due to traumatic injuries, inflammatory disorders as synovitis/capsulities, inflammatory arthritis, capsular fibrosis, ankyosis, subluxations, spontaneous dislocations, chronic (recurrent disclocations) contributing to clicks and audible popping sounds. Fractures and hemarthrosis within the TM Joint should also be considered. Masticatory disorders (muscle pain), chronic mandibular hypomobility, mandibular hypermobility, growth disorders of the jaw (i.e. coronoid hyperplasia), and functional abnormal jaw closure patterns also be recognized. Common misdiagnosis’ are fibromyalgia, migraineous head pain, neuralgias of the masticatory system as well as cervical/neck/ shoulder and back pain. The area of the face where the TMD is located is an intricate network of bones, including the teeth, muscles, and nerves. Because of this, TMD (dysfunction) conditions affect many areas of the body, from the top of the head in migraine-like headaches to numbness or tingling of the arms and pain in the neck or shoulders.

The majority of people suffer to a greater or lesser degree from TMD. Although women report more pain from TMD, TMD in men causes as much or more damage to the teeth, gums, bones and joints. Children are especially sensitive to TMD and usually show early signs with ear infections, leaning their head on an arm, lip, cheek, or finger biting, sucking or chewing, headaches, snoring, grinding of their teeth at night, and significant chewing of gum.

In most cases, TMD disorders stem from a condition called malocclusion, which means having a “bad bite” or accidents and trauma. Malocclusion means that your upper and lower teeth do not close together in the correct way—they are misaligned. This includes underbites and overbites. When the teeth are misaligned, they cannot provide the support the muscles in the face need for chewing and swallowing. These muscles are then forced into a strained position, resulting in pain throughout the face, head, arms, shoulders, and back. Although a person may have beautiful teeth or had orthodontics to line the teeth up for aesthetic reasons, the muscles and joints may not be comfortable.

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).

Finger & Thumb Sucking as Infants:

As you can imagine, this will help to dictate the formation and the morphology of the jaws. Finger & thumb sucking can be very detrimental to the proper development of the jaws, facial structures, and to airway development which can then lead to TMD in adult years.

Artificial Feeding of Infants:

As we all know, breast feeding is the best option for providing optimal nutrition to infants. Human breast milk is very high in nutrients and anti-bodies which help our babies’ immune systems to become very powerful which then enables them to overcome not only multiple diseases, but to fight off allergens, which we will get into in a minute. • Also, the human nipple is perfectly shaped such that when an infant breast feeds, ideal lip and jaw position take place facilitating proper development of the jaws, facial structures, and the airway. • As we all know, breast feeding may not be an option…in fact, my own children were bottle fed! It is very important to know that using the correct nipple when bottle feeding can help to facilitate proper development of the jaws, facial structures, and airway. This nipple is the Nuk nipple which was developed in part by the late Dr. Jim Garry who was a pioneer of Neuromuscular Dentistry and the world’s leading expert on airway development of infants. The Nuk nipple has the closest resemblance to the human nipple & therefore, helps to form the infant jaws, facial structures, and airways properly.

Allergies:

As mentioned earlier, breast feeding is the best source of nutrients for our infants…one major reason being that the anti-bodies that it provides helps our babies to develop an immune system that can fend off allergies. I’m not saying that breast-fed children don’t get allergies, sometimes it just happens no matter what. The point is when an infant develops environmental allergies, the turbinates in the nose swell causing nasal congestion, the tonsils & adenoids swell causing airway obstruction, and mouth breathing then takes place. Chronic mouth breathing invariably results in malocclusion (or having a bad bite) because the tongue is not resting up on the palate. This is crucial for proper upper arch development, otherwise the upper arch becomes constricted and teeth grow in crooked resulting in the bad bite, causing the muscles to work harder to bring the jaws together.

Trauma:

Trauma to any area of one’s body has the potential to cause chronic, long-standing problems. As we all know, sometimes traumas can be treated with 100% healing & recovery, and sometimes they cannot…it merely depends on the patient and the situation.

Overall

Skeletal Development: Sometimes, we just form incorrectly due to genetic reasons. One may be born with a syndrome or some underlying medical condition that dictates a dysfunctional skeletal development.

TMD is most often caused by a bad bite, or malocclusion, which causes unbalanced, unhappy muscles that are constantly in a state of spasm trying to find a comfortable position. When your lower jaw does not close on the correct path of closure, and the teeth do not come together properly, your body recognizes it, and the body elicits a subconscious action to attempt to find a comfortable position for your lower jaw to rest in. This subconscious action of trying to find a comfortable position is mediated by the Central Nervous System and is referred to as para-function. Some examples of para-function are clenching, grinding, and protrusion of the lower jaw. Within our brains, we have an area located in the Mid-Brain called the Reticular Activating System (RAS) which serves as the brain’s “on-off switch”…the RAS is activated by para-functioning. Therefore, when we subconsciously grind our teeth at night during sleep, the “switch is turned on” in the RAS which makes one sleep even lighter & causes more grinding (bruxism) resulting in even poorer sleep which increases our stress which in turn lowers our adaptive capacity to handle stress! As you can see, this can be an ongoing, never-ending, negative feedback loop if the loop is not intercepted!

Adaptive Capacity

We all have an adaptive capacity which is simply our ability to accommodate and cope with the stresses of everyday living.

Pain is a sign of too much sensory information and too many signals being sent beyond the adaptive capacity. When this happens, our bodies recognize it, and elicit postural accommodations and protective mechanisms such as forward head posture or limping to accommodate for the pain causing more muscle tension. Then, the negative feedback loop mentioned earlier kicks in again adding even more noxious stimuli and a whole new set of problems. A great analogy for this is having a rock in your shoe. The rock hurts our foot so we limp on that side which then causes our hip on the other side to hurt. This is called avoidance conditioning…we accommodate to avoid the noxious stimuli. To treat it, we don’t go to the doctor to have hip surgery, we remove the rock from the shoe. We treat the cause, not the symptom. This is really important in the treatment of TMD…taking drugs to minimize or mask the pain is treating the symptom and it is just a Band-Aid for the real problem…treating the underlying cause is what must happen to actually eliminate the disease process

Limbic System

60% of all sensory input that comes into the body enters and is filtered through the Trigeminal Masticatory System (your jaws & teeth). This input is then sent to an area of the Mid-Brain called the Limbic System. The primary function of the Limbic System is to filter information and control emotions and behavior. As you can imagine, a person in pain with a small accommodative capacity and narrow goal posts because of the pain and an overloaded Limbic System can perpetuate many negative hyper-emotions such as hostility, anger, and crying. This is why many patients with TMD are coined in the medical profession as “crazy”…they are not crazy, they are in pain and have been for years! Their Limbic System is on overload and has to dump somewhere in order to survive.

Many times we lash out at loved ones or an innocent bystander when they weren’t the cause of our anger or problems at all. The kids not getting up in time, the car not starting, hitting every red light in town, and people driving too slow made you late for work which upset your boss and also got you behind all day which made you work twice as fast so you made mistakes which upset your boss again which made him have to counsel you which made you mad. Sound familiar? But, it was all of the other negative stuff that accumulated all day long that had nothing to do with it, that made you fly off the handle. That’s an example of an overloaded Limbic System…it had to dump somewhere before you went crazy, and it happened to dump right in the lap of someone else. This happens to all of us. The smaller our accommodative capacity, the faster our stress bucket overflows and has to dump!

Stress is not a cause

Many times, we hear our patients and other professionals say that stress causes TMD. In fact, stress is not a cause, but it can certainly exacerbate an underlying condition that may be otherwise dormant. Many patients and professionals also think that grinding (bruxism) causes TMD. In fact, I always have patients say to me, “Doctor, I don’t even grind my teeth, so why am I in so much pain”? The answer is that every time you swallow, which is 2,000 times per day, your lower jaw (mandible) swings on the wrong path of closure, and the teeth come together incorrectly causing muscle spasm causing pain.

Dr. Clayton Chan, former director of Neuromuscular Dentistry at the Las Vegas Institute, always says, “Keep the main thing the main thing”. Here is the “main thing” for you to know. Misaligned teeth bring about misaligned joints causing the joints to exist in a pathological position which, in turn, causes the lower jaw to be in the wrong position, which causes it to close on the incorrect path, which causes muscles to spasm which causes pain.

Today, our dental professions diagnostic paradigms are evolving beyond only identification of dental caries, marginal breakdown of old fillings and crowns, root canal lesions, fractured teeth and periodontal breakdown. These basic dental problems are often only indications of a more hidden muscular, occlusal and temporomandibular joint problem that go often undetected, even within the medical and dental profession. TMJ/TMD is a problem that is not easily seen by cursory dental x-ray and intra-oral evaluation. It presents with many signs and symptoms that can mimic other medical and dental problems as vascular disorders, brain tumors, aneurisms, cervical disc disorders, throat and oral cancer, etc.

Some of the numerous signs and symptoms may include clicking, popping and grating noises of the jaw joints. Consider the tender paining temporal muscles on the side of the head. Tender and sore muscles behind the head and neck (sub-occipital cervical region) as well as upper shoulders can be part of this problem. Muscles under the chin, the facial muscles (side of face), limited mouth opening, loose teeth, clenching/ bruxing, postural problems, paresthesia of fingertips and hands, nervousness, insomnia are just a few of the many different signs and symptoms of TMJ. What about those cases with non-specific facial pain, tenderness on palpation of various sites of the head and neck? Teeth sensitivities and aches, ear congestion feelings, pain behind the eyes, tingling in the arms and fingers, dizziness, ringing in the ears, etc., all relate to the dental aspect of TMJ. Many of these symptoms are related to and are associated with the living tissues that effect the mandibular position and in turn effect upper to lower teeth relationships and vice versa.

Crowded lower front teeth, wear of the lower incisal edges, fractured cusps, narrow arches, deep palates, over-closed bites, flared upper front teeth, receding gums, mobile teeth, loss of molars, cross bites, to name some of the intra-oral signs.

Extra-oral signs as: facial asymmetry bilaterally, short lower third of the face (chin to nose point diminished), chelitis, abnormal lip posture, deep mental crease on chin, dished-out or flat labial profile, facial edema, mandibular torticollis, cervical toricollis, forward head posture (lordosis) elongated lower face (steep mandibular angle), and speech abnormalities, should all be considered as abnormal signs. The human body, which includes the teeth, the muscles of the head and neck, the TM Joints, the neurology that innervates the system of mastication and posturing of the head and neck are all parts of what the dental profession should consider when diagnosing and treating our patients comprehensively.

If you are experiencing such and are not getting better you are not alone. These type of symptoms are signs of temporomandibular joint dysfunction (TMJ) which are a common problem among 10 million people in the USA. Approximately 1 in 27 or 3.68% of all people in USA experience these types of symptoms daily (National Insititute for Dental and Craniofacial Research). Many TMJ patients have received numerous listed medical and dental treatments with little to no effective relief of their pain. Many of the treatments have been recommended based on the doctors preference and not based on sound objective measured scientific evidence for both saftey and effectiveness. Some treatments have been tried, some invasive, irreversible, and made the patient worse, leaving the patient in a dilemma of financial loss, disappointment, depression and dispare.

• Facial pain
• Jaw joint pain
• Back, Neck, cervical pain
• Postural problems (forward head posture)
• Pain in the face
• Limited opening of the mouth
• Headaches (tension type)
• Pain in the muscles surrounding the temporomandibular joints
• Pain in the occipital (back), temporal (side), frontal (front), or sub-orbital (below the eyes)
• Pain behind the eyes – dagger and ice pick feelings
• Multiple bites that feels uncomfortable or, “off,” and continually changing
• Clenching/bruxing
• Tender sensitive teeth to cold
• Deviation of the jaw to one side
• The jaw locking open or closed
• Ringing in the ears, ear pain, and ear congestion feelings
• 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.

The NIH Technology Assessment Conference Statement concluded that, “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.”

The medical and dental community usually diagnoses TMJ based on range of motion tests, listening for sounds in the joints, examining the teeth, and manual palpation of the jaw joints as well as the muscles of the face, and head. Typically the dentist may ask for information about your pain and other symptoms, injuries, oral habits, and previous medical and dental treatments. A subjective assessment and examination may be completed, but often without confirmation of objective measured instrumentation and analysis, which is now becoming a standard with the community scientific methodology and standards and those clinicians who are seeking a higher standard of objective care for their patients. 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.

Musculoskeletal Dysfunction 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.

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 TMD evaluation, we encourage you to then obtain multiple INDEPENDENT opinions on your condition. TMJ/ TMD disorder is persuasively viewed as in the case of Masella v. Blue Cross & Blue Shield of Connecticut (United States Court of Appeals for the Second Circuit, 1991) as principally related to the jaw joints rather than the teeth. In spite of having had non-surgical treatment as biofeedback therapy and an orthotic appliance designed to reposition her jaw, the United States Court of Appeals for the Second Circuit affirmed, ruling that TMJ was a medical, rather than a dental disorder and was covered under the relevant policies. The basis for the insurer’s declining the claims was, as typical, that the treatment was dental in nature (rather than medical) and was thus excluded from coverage under the relevant health insurance policies containing “dental” exclusions.

INITIAL TREATMENT FOR TMD

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 provided 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.

3. Surgery is the last and least recommended when irreversible damage has occurred in the joints and is beyond natures healing capacity. TMD treatment occurs in two phases. Phase I treatment is diagnostic in nature in that it’s purpose is to find the ideal resting position of the lower jaw and its muscles, the ideal path of closure, and the ideal bite. This is done through diagnostic testing using computerized instrumentation to find the proper new resting position of the mandible. Non-surgical, orthotic therapy or stabilization is done in this new position.

The key to treating TMD, is getting the muscles out of spasm, relaxed, and happy.

To do this, we will pulse the muscles & relax them into a more natural, down and forward, untorqued position using a TENS unit. Once the muscles are relaxed, we will verify muscle activity using EMG’s. After verifying that the muscles are relaxed according to the EMG’s, the bite is then recorded on the proper path of closure, or trajectory, at this new relaxed position, and this path is verified using Jaw Tracking. This new, relaxed position is called the Neuromuscular Position. Therefore, this type of dentistry is called Neuromuscular Dentistry (NMD). Notice, all of the diagnostics along the way are verified and measured using instrumentation…there is no subjectivity or guesswork! Once the orthotic is made in the new, neuromuscular position, this phase could take from three months up to two years depending on how the patient responds. Once the bite is stabilized and the patient is symptom-free, happy, and comfortable, the patient can then move into permanent or Phase II treatment. Phase II treatment is definitive in that it places the teeth into the new position that has been in function on the orthotic for the past several months. This can be done either orthodontically (with braces) to move the teeth into the new position or it can be done restoratively by placing crowns on the teeth to lock them into the new position. The course of treatment is determined by the patient’s specific situation and desires. They may also choose to wear the orthotic long term and not proceed with any permanent treatment.

Dental insurance does not usually cover TMD treatment, but sometimes, medical insurance will cover some of the costs associated with Phase I treatment. It merely depends on your particular health insurance policy. We will give you the necessary forms and insurance codes to help you with reimbursement.

Many of you reading this article have probably experienced a headache at some point in your lifetime. An occasional headache is not usually something that requires the help of a medical professional. Most people take an over the counter pain reliever and go on with their lives. However, there are millions of people who live with frequent or chronic pain in their head and neck. Some of these people can have so much pain at times that it alters their normal daily activity and state of mind. The pain can get so intense that it causes them to seek medical attention. Some are diagnosed with migraine headaches. Migraines have become an overused and often misused term in the past few years. A true, classic migraine is thought to be a nerve/vascular event that occurs in the brain causing symptoms including intense headache, usually on one side of the head with nausea and sensitivity to light. The diagnosis is made from the patient’s report of symptoms only, no scan, image or blood test can show it.

More commonly, patients suffer from tension headaches. Tension headaches are simply (as the name implies) muscles that are tense and in spasm, causing pain. Muscles can tense and spasm with overuse, improper posture, skeletal misalignments and improper function of the movable parts of the body. When a muscle in any part of the body is in spasm, there is decreased blood flow and oxygen to the muscle which results in a buildup of a chemical called lactic acid. Lactic acid causes an intense pain response until the muscle relaxes and blood flow is restored. When this happens in the head and neck region, the pain is intensified, compared to other parts of the body, due to the proportionately larger number of nerves per square inch in the head and neck. In some patients, the pain of muscle tension can be so intense, that it causes nausea, pain in and around the eye, making them take pain medications and sit in a dark room. These symptoms mimic the classic migraine which is a less frequent type of headache. The National Institute of Health estimates that over 30 million people suffer from migraines, and the diagnosis is made purely from report of symptoms from the patient and CAT scans or MRI’s ruling out a tumor or brain abnormality. So, if tension headaches can cause the same intense symptoms, how does one know which type they are having?

Until recently, there was no way to distinguish between them. Treatment was with trial and error trying various types of prescription drugs like pain relievers, anti-depressants, muscle relaxers and even blood pressure medications. These medications in different combinations offer some patients varying levels of relief; however, they treat the symptoms not the source.

Statistically, a large majority of head and neck pain is muscular in origin. There is always a cause for muscle tension, it’s not a normal state, and pain is an indicator that something is wrong. The lower jaw is supported by a host of muscles in the head and neck that work together to allow normal function. If the bite is out of alignment (malocclusion), this can cause some or all of those muscles to become tense and spasm, as they try to accommodate to the bite position. It often results in headache, neck and shoulder pain, ear pain, pressure or ringing, dizziness or pain behind the eyes. Even if someone has had orthodontics (braces) to esthetically align the teeth, the muscles may not be comfortable in that position, resulting in these symptoms of varying degrees.

There is exciting new computerized technology available in a growing number of dental offices around the world, that allows the dentist to objectively identify and measure the location and amount of muscle activity in the head and neck, which can help distinguish between muscular and migraine headaches. With the aid of EMG’s (same technology as EKG), joint sonography, and computerized jaw tracking, the dentist can objectively tell if the jaw is improperly aligned, and if the muscles are in spasm. After the muscle activity is measured, the muscles are then relaxed with the use of ULF-TENS (Ultra Low Frequency-Transcutaneous Electronic Nerve Stimulation) which is a way to relax the muscles with a gentle “massage “of rhythmic pulsing that increases blood flow and pumps out waste metabolites like lactic acid that cause the pain. The computerized jaw tracking is then used to find a relaxed jaw position for the patient that the dentist can make a customized temporary orthotic that is worn on the lower teeth in order to stabilize the bite in that relaxed position.

We have this advanced technology in our office and have been treating patients successfully for the past few years. The results can be dramatic and life changing for many patients. Many of the patients treated have been to multiple physicians, had multiple tests performed, trying desperately to find the solution to their symptoms. Many of these dentists work in conjunction with other health professionals like physical therapists, chiropractors and acupuncturists in order to treat the supporting areas of the head and neck to relieve muscle pain in those areas as well. The goal is to treat the source or cause of the pain, returning the body to a normal state of function. To find out more about this exciting treatment, you can log onto our website at www.drcraiglandry.com or call 337-981-9242 x2 to schedule a headache consultation.