Archive for the ‘tmj’ Category

Neck Pain of Craniomandibular Origin Unassociated With Trauma

Friday, May 7th, 2010

A complete discussion of the cervical spine and its relationship to the craniomandibular system would require a several day seminar.  The comments to follow will begin to develop the impact of mandibular posture to cervical dysfunction and pain.  The resting relationship of the movable mandible to the fixed maxilla is influenced by many factors.  These include dental occlusion, respiration, TM joint anatomy, muscle function, cervical posture, and tongue position.  Of course determining which is the cause and which is the effect is why a comprehensive diagnosis is necessary prior to proceeding with any treatment for craniofacial pain and dysfunction.

In all humans, mandibular orthopedic relationship to the maxilla is determined by maximum tooth-to-tooth position.  The muscles, TM joints, and cervical spine accommodate to posturally reposition the mandible in order to allow maximum intercuspation of the teeth.  Accommodation to bite discrepancy occurs in the entire upper quadrant, especially the cervical spine and more specifically the upper cervical spine, C-1 and C-2.  Structural relationships within the upper quadrant are extremely complex and so entwined that abnormalities or stress within one area can produce pain and dysfunction in another.  When the individual’s ability to accommodate is exceeded, symptoms occur.

In patients who present with mandibular orthopedic discrepancy as well as cervical discomfort, jaw orthopedics must be evaluated as the primary or secondary stressor for cervical pain and dysfunction.  The proper application of Ultra Low Frequency TENS combined with specific masticatory and cervical muscle response, as revealed through electromyography, provides diagnostic data, which frequently reveals the true source of the patient’s cervical pain.  Any treatment recommended can thereafter be directed properly resulting in efficient, effective and lower cost therapy.

More regarding this complex subject of Trigeminocervical relationships to come.

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TMD Treatment for Headache: a case history

Wednesday, February 17th, 2010

Our experience with headache patients is typified by our patient Beth (the facts of this case are true, only the names have been changed to protect the innocent.)   Beth was referred to me by a neighbor for evaluation of chronic jaw dysfunction including clicking and popping jaw joints, jaw-locking open and closed, and jaw muscle pain.  Other significant complaints included chronic severe migraine headaches, frontal headache, occipital headache, and neck pain.  She was under the care of her physician for migraine headache treatment with daily medication and 1-2 visits weekly to the hospital emergency room for injections.  She was also receiving chiropractic treatment 2-3 times weekly for neck pain.

A complete craniofacial pain diagnostic workup was performed in my office.  The results of these evaluations revealed Beth suffered severe jaw muscle dysfunction, chronic jaw muscle spasm, and moderate destructive bone changes in her jaw joints.  Careful analysis of jaw muscle and temporomandibular joint function using electromyography and computerized jaw motion analysis indicated a removable oral appliance could correct many of the jaw movement problems.  The removable orthotic was delivered and Beth was instructed to wear the orthotic at all times.

Within the first week of wear, she had a dramatic reduction in her headache intensity and frequency.  From the first week, Beth never again needed to go to the emergency room for headache treatment.  Over the following months, her chiropractic adjustments were reduced and she no longer required prescription headache medication.  At approximately 14 months, the orthotic wear was gradually reduced to nighttime wear only.  At her 5-year follow-up evaluation, Beth continued to be virtually headache free.  Her current dominated complaint is continued neck pain, which is controlled by chiropractic treatments 2-3 times monthly.  Beth continues to wear her oral orthotic every night and there has been no further destruction of the jaw joint bone.

Unfortunately, Beth suffered for many years inspite of regular medical, dental, and chiropractic care by good caring doctors doing the best they could to help her.  The problem was they simply were not trained to recognize the signs of jaw dysfunction, which had been present for years.  It was Beth’s neighborhood friend, a chiropractor, who made the connection and as a result changed Beth’s life for the better.

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TMD and Headache

Friday, February 12th, 2010

Headache (cephalgia) is a common complaint among TMD-TMJ patients.  Consulting the literature on the incidence of headache yields widely varying results in study populations.  This is due to the wide variety of craniofacial pain symptoms, including headache, and the various methods used to categorize headache pain.  In spite of this epidemiologic confusion, there are some things we “kind of” know about TMD and headache.  Based upon current studies it seems that between 14% and 26% of all headaches are associated with TMD and over 90% of TMD patients list headache as a primary symptom.  Muscle tension headache appears to be the dominant type of headache and may be mild or debilitating.  Migraine headache is also strongly associated with TMD.  Although published studies offer scarce information on this relationship, clinical observations support the consideration of TMD as a cause of significant numbers of migraine headache.

In my own practice over 80% of TMD patients presenting with migraine type headache achieve significant or total relief.  As with all medical disorders, a very thorough diagnosis with identification of contributing factors is key to effective therapy.  In my experience, deficiency of diagnostic evaluation is the chief cause of treatment failure.

More of this subject later.

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Cervical Whiplash and TMJ

Wednesday, February 3rd, 2010

It is a matter of common sense that a direct impact to the lower jaw, temple, or temporomandibular joint can result in injury to the TM joint.  A lesser-known mechanism of injury is the TM joint injury resulting from trauma to structures, which directly or indirectly provide attachment to or are functionally related to jaw biomechanics.  Neck whiplash injuries are a common cause of late onset symptoms of jaw dysfunctions.  Several scientific studies have looked at this specific relationship.  The most recent study by Sale and Isberg, published in the Journal of American Dental Association in 2007, reported the incidence of new TM disorder symptoms was 5 times higher in the whiplash injury group as compared to the control group.  In the whiplash group, 2 out of 3 patients reported onset of symptoms within 12 months and 20% of the whiplash group stated TMD as their major complaint.  Our clients often present with TMD complaints months or years following their whiplash injury without ever having been evaluated for TMD prior to settlement for medical cost of treating the whiplash injury to their neck.  TMD treatment then becomes an out of pocket expense and cost alone may prevent the injured person from receiving effective TMD treatment.

The important points to remember are

1)      Cervical whiplash alone without direct impact to the temporomandibular structures results in the development of significant TMD complaints in 2 out of 3 whiplash injuries

2)      If yourself, a friend or a loved-one suffer a neck whiplash injury from a fall or motor vehicle accident, monitor closely for at least 12 months for the development of possible TMD related symptoms

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TMJ and Ear Pain

Wednesday, January 27th, 2010

Patients frequently present with mysterious pain or other symptoms in the head and jaws, which they do not associate with jaw dysfunction (TMJ-TMD).  Recently a woman presented with the primary complaint of ear pain.  Thinking she had an ear infection, she sought care from her primary physician and an ENT (ear, nose, and throat physician).  Both assured her there was no evidence of infection but they did not have an explanation for the pain and gave no recommendation for treatment.  She explained to me that although her jaw joints clicked and popped, she did not experience jaw joint pain or limitation of movement.  She had come to see me on recommendation of a friend and was uncertain how a dentist could help her ear pain.

The explanation of the mysterious ear pain is actually well understood.  The ear pain was what we call “referred pain” resulting from pinching of a branch of the auriculotemporal nerve as it passes thru the temporomandibular joint on its way to the inner ear.  Treatment of the underlying jaw dysfunction resulted in relief of her chronic ear pain.

One of the challenges to effective treatment of chronic head and jaw pain is proper diagnosis of the cause, which is often not immediately apparent.

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Bacteria and TMJ Pain

Tuesday, January 19th, 2010

Recently, several studies have demonstrated a relationship between bacterial infections and degenerative TMJ disease. A study by Drs. Hughs, Hudson and Wolford published in the Journal of Maxillofacial Surgery (2000) found the bacteria, Chlamydia trachomatis, associated with the sexually transmitted disease Chlamydia, were present in 65% of a TMJ surgery patient group. Other studies have reported the presence of more than one bacterial species commonly found in the urogenital tract present in the TM joint.
Many TMD-TMJ practitioners are now screening patients who present with TM joint internal derangement or degenerative joint disease for these bacteria. Your physician can order a simple blood test for the presence of these bacteria and if detected may recommend treatment with antibiotics. Additionally, this test should be repeated in patients with continued TM joint pain following otherwise successful treatment for TMD symptoms. It may be the key to ultimate success in relief of pain and dysfunction for many TMD-TMJ sufferers.

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