TMD Joint Issues
Temporomandibular Disorders (TMD) should not be confused with Temporomandibular Joint Dysfunction and is recognised by experts as a collection of symptoms that affect hard and soft tissues of the oral cavity, facial muscles and skeleton.
There are three TMD’s commonly seen in general practice.
By the time referral is made, it has often developed into a chronic pain condition; this can complicate the management. But with a multi-disciplinary approach most patients can be helped.
All chronic pain conditions share some common features:
Patients become sensitised to their pain (they don’t feel less pain, they feel the pain more severely).
They are likely to develop comorbidities (have other things wrong with them).
They are likely to suffer poor quality of sleep.
Some chronic pain patients unfortunately feel that their family, friends, health care professionals have undergone “condition fatigue” for the distress in which they find themselves. This can lead to the patient feeling that they have reduced empathy and support.
Some changes in the brain will have occurred due to the long-term pain input. Patients become sensitised to their pain (they don’t feel less pain, they feel the pain more severely). They are likely to develop comorbidities (have other things wrong with them). They are more likely to suffer poor quality of sleep. Some chronic pain patients unfortunately feel that their family, friends, health care professionals have undergone “condition fatigue” for the distress in which they find themselves. This can lead to the patient feeling that they have reduced empathy and support.
A recognition of these features is essential for the patient to get better: it means there is no magic bullet for this multifactorial pain condition. Some very valuable research by Professor Justin Durham at Newcastle Dental school has shown that the biggest predictor of a successful outcome for a myofascial pain patient is to be given a diagnosis, even a provisional diagnosis at the first appointment.
This is our aim, even if it is to tell you that you don’t have a TMD, so we can get started at looking at other causes.
If a diagnosis of myofascial pain is made, you will expect a Management Plan. This will vary from patient to patient, but will fall into 3 broad headings:
Muscle Therapy: the pain of myofascial pain is a myalgia, ie a pain from the muscles. So clearly, this is a good place to start. In addition to some simple thermal strategies, we are fortunate at Clinic 334 to be able to call at the services of the Chairperson of the Association of Chartered Physiotherapists for the Study of TMD. We may also consider in resistant cases and in conjunction with your GP, various muscle relaxant medications, although rarely as an initial measure. Botox injections into tender and tight muscles is sometimes considered, despite the evidence that the benefits may be short-lived. If we advise this, we refer the patient into the expert care of a Consultant OroMaxilloFacial surgeon. Botulin Toxin is a strong toxin and in my view is best administered by this level of expertise.
Occlusal therapy: at the outset these must be removable, reversible and non-invasive and this means occlusal splints. There are many types of splints available, some are good and some are less good and a few can be dangerous because they allow permanent changes in the position of the teeth. We are from a university research background and therefore only use splints that have an evidence base. In rare cases, there may be a justification for making some superficial changes to the shape of some teeth. This is not “spot grinding” and we would only ever consider it after planning it first on accurately mounted models of your mouth, so we know the desired changes are achievable.
Developing better coping strategies for the pain: there are many useful techniques to try to reduce the adverse effect of chronic pain. This is not our area of expertise but we can usually steer the patient in the right direction to get the most appropriate help.
Internal derangement of the temporomandibular joint (TMJ):
Essentially, this means that there is a problem with the disc in the TMJ. It may be damaged or have moved position, resulting in a click or lock of the joints. Some of these conditions need no treatment other than an explanation, reassurance and some simple protective measures.
Others may need a simple surgical procedure that involves a short general anaesthetic but not open surgery of the joint. We work closely with experienced Oromaxillofacial surgeons if this is needed. Very few need open surgery to the joint, and only after we have exhausted all other conservative measures.
This is wear and tear of the TMJ and, if indicated, helpful measures are designed to reduce the load on the joint.
In summary, the key to successful management of TMD is to make a diagnosis, and only then can an appropriate management programme be designed.
In the vast majority of cases, it is possible to establish a working diagnosis with specialised examination protocol that was developed at the University Dental Hospital of Manchester. This is used to look at the health, function and comfort of the TMJ’s, the masticatory muscles and the features of occlusion. Although it tests some areas for tenderness, it is not a painful procedure and does not involve any invasive procedures. Usually there is no need for x-rays or scans. Solutions for TMD vary from non-surgical or self-managed treatments up to surgical procedures for extreme cases. At your initial consultation our team will assess your issue and create a personalised treatment plan.
Occlusion in dentistry
Occlusion is the fancy word for the “bite”. It describes the relationship between the teeth when they touch. Not only when they close together (the static occlusion) but also the slightly more difficult to analyse contacts when you slide your teeth against each other, the dynamic occlusion.
A study of occlusion also involves determining the relationship of the jaws that the patient’s occlusion determines.
There is the potential for dentists to change the occlusion because so many dental procedures involve the biting surfaces of the teeth. In the vast majority of cases where there has been some change, the patient will adapt to it without any lasting problems. However, in a few cases, the change may exceed the patient’s adaptive capability. Although the likelihood of this happening is low, the consequences can be severe, with significant quality of life issues. Patients who have suffered significant discomfort and loss of function, following changes to their bite, are the ones that Stephen has been able to help for the past few decades of his practice..
It is important to understand that this help does not necessarily mean redoing all the recent dentistry.
This lack of adaptation can be of several different levels:
The teeth or restorations:
o Keep breaking
o Are pushed (migration)
o Wear in odd or excessive ways
o Be painful, even leading to pulpal (nerve) damage
The all important periodontal structure:
o Widened leading to temporary tooth looseness or mobility
o An existing periodontal disease may be exacerbated
The support system for the jaws, made up of the TMJ’s and muscles may be affected
Many but not all of these problems can be resolved by short term and non-invasive measures. These may include some sophisticated removable Occlusal Appliances or splints and measures to improve muscle health.
Some patients may need more than these simple measures, some much more. This is especially true if the existing restorations are less than ideal in some other ways.
In a few cases, a full mouth reconstruction may be needed. This term doesn’t mean restoring every tooth in the patient’s mouth. It means looking at the mouth, with all its elements, as a functioning unit and devising a plan to restore it back to optimal health, comfort and function.
We mention this to reassure you that if you are in this unfortunate position, all clinicians at Clinic 334 are well practiced in the complex and careful techniques that are needed to take someone who is currently orally disabled back to having a healthy, comfortable and functioning occlusion.
Initial consultation fee will be £340, including initial “x-rays”/radiographs leading to a written report. Treatment fees vary greatly depending on the case.