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TEMPOROMANDIBULAR DISORDER (TMD) Also known as TMD, this is a disorder as opposed to a disease. One could even say that almost everyone has some degree of TMD. First, lets define it and review the signs (conditions viewed by the dentist) and symptoms (complaints by the patient). After we have a basic understanding of what it is, we will then move onto the causes and the treatments. This page contains a lot of information and TMD sufferers are advised to carefully read through and, where necessary, re-read the relevant sections. Having this information at hand will allow you to review and better digest the information. Important Note for TMD patients about to receive dental treatments:There are occasions when patients with TMD will have difficulty,
pain and jaw discomfort during dental treatment. This is not actual discomfort
from the procedure itself but rather pain due to muscle spasms as the
jaw is maintained in an open position during treatment. This usually
manifests part way through an appointment when the patient starts to
rub/massage the jaw muscles. During the appointment, the muscles become
continually more sore and overall discomfort increases, making it difficult
to finish the appointment.
Signs and/or Symptoms of TMD: The Temporomadibular System is made up of three anatomical subsystems, all used for mastication/chewing. These are the muscles of mastication, the teeth and the temporomandibular joint (TMJ): MUSCLES OF MASTICATION. These are the muscles attached to the side of your skull at one end and to the lower jaw at the other end. Their main purpose is to move the lower jaw against the upper jaw in order to masticate/chew your food. Signs and Symptoms of muscle involvement on TMD can include some or all of the following:
It is interesting to note, that headaches due to TMD can often be confused with other conditions such as migraine headaches and other less common forms of headaches, e.g. Neuralgia, Atypical Facial Pain, Cluster headache, etc. For this reason, you may be given a DIFFERENTIAL DIAGNOSIS as opposed to a (definitive) DIAGNOSIS until further diagnostic testing can be done. TEETH. When the teeth are involved, it is generally because they are being used at times other than chewing food. We refer to this as PARAFUNCTION. Parafunction is the most common cause of TMD and we will look at this further on. For now, lets just look at the signs and symptoms of TMD, relating to the teeth. These are:
TMJ (Temporomandibular Joint). as with all moving parts, there needs to be a joint. What makes the lower jaw (mandible) unique is that it is essentially one bone with two identical joints. These two joints (left and right) are both located very close to the front of the ear holes. To find their locations, simply put your finger on the small flap of skin(tragus) on the front of the ear hole and move your lower jaw. You should then feel the bulge of the TMJ as it moves, especially when you move your jaw from side to side. TMD signs and symptoms can include some or all of the following:
OTHER POSSIBLE INDICATORS . In addition to the above, there are several other common signs and symptoms which may be associated with TMD. These can include the following:
It is very important to remember that there are several other conditions which can easily be confused with TMD. Just because you have all or some of these symptoms, you must avoid self diagnosis. Further testing is usually required in order to make the definitive diagnosis.
Causes of TMD: The most important aspect of TMD is understanding the CAUSES. Causes of TMD include the following:
Of all the causes of TMD, parafunction accounts for the vast majority of cases with trauma being a very very distant second. In today's society, it seems that the stress and strain of daily life seems to be causing more and more people to grind and clench their teeth. I am sure we can all relate to times in our life when stress has caused us to clench or adopt other nervous habits. Sufferers of TMD due to parafunction may not be aware of their habit since they do not do it consciously, especially when they do it in their sleep. Let's look at the various factors individually:
SLEEP. Believe it or not, sleeping patterns are probably among the most destructive aspects for many of us. Frequently, the dentist can view the wear patterns of the teeth and determine the sleeping patterns leading to the tooth wear. We refer to this as a DESTRUCTIVE SLEEPING PATTERN (DSP). DSPs are usually side and stomach sleeping patterns where the patient has a twist in their spine during sleep. At the same, time, they frequently hold their hands/arms up to the face or place the pillows or blanket rolls under the jaw. Sometimes side sleeping patterns are a result of the patient being awakened by a sleeping partner as a result of snoring. TMD as a result of DSPs may not be the only problem. Many times, DSPs may lead to other problems such as wrist, neck, upper/lower back and shoulder problems. It is frequently seen that TMD sufferers commonly see other health practitioners, such as physicians, chiropractors, physiotherapists, massage therapists, etc, for relief of carpal tunnel syndrome (where do you place your hands during sleep?), and upper body and shoulder soreness. One possible clue that you have a DSP is if you wake up feeling worse than when you go to bed. People with DSPs commonly wake up and complain of jaw soreness, sensitive teeth, sore shoulders, neck, back and wrist. Remember, it is very common for DSP sufferers to wear wrist and neck braces as well as frequent allied health care professionals.
As mentioned, DSPs due to a person's habit of sleeping may cause the above problems. On the other hand, DSPs may be caused by some of these problems as well. Other than sleeping on a poor mattress, or being turned over due to excessive snoring, some TMD sufferers have adopted a DSP because of a sore shoulder or hip or any other physical condition that may influence their sleeping pattern. Occasionally, pregnancy may fall into this category. Being aware of DSPs is the first step to treatment. As an exercise, we recommend you look in a mirror and put your front teeth together until the wear patterns match. This is usually when you cannot see any space between the teeth. Then lie down in your bed and figure out which position allows you to do this. Important note on parafunction: In all cases where parafunction is the cause, it simply means that the teeth are touching when they are not supposed to be. In normal rest position, the teeth are generally 1 to 4mm apart and the muscles are at rest. Function of the teeth with regard to chewing means that the teeth and muscles are used for approximately 17 minutes every day. That's how much the average person actually makes chewing tooth-contact every day. Imagine what happens when you put those teeth under additional heavy load. Remember, the teeth cannot touch unless the muscles are in contraction. Once you load the system, now the teeth, muscles and jaw joints (temporomandibular) become involved. Now imagine doing this for several hours a day under a heavy load. This now becomes a self-destructive process.
POSTURE. (Although sleep posture technically belongs here, we have dealt with this separately in the preceding paragraphs.) Typically, postures with a head-forward position, can typically promote parafuction during the day time. Some people naturally hold their head in that position during the day whether walking, standing or sitting. More commonly, head-forward positions may be work associated with arm-forward postures. The most typical will include computer/keyboard positions and professional drivers. Doing these activities all day long and concentrating on the task at hand can lead to grinding and clenching habits. As a general rule, the TMD symptoms and signs due to work related posture tend to worsen during the day and are the worst in the evening.
BEHAVIOUR/HABIT. For whatever reason, people with little or no predisposing factors engage in parafunction simply due to habit. It has been reported that females whose mothers are grinders/clenchers, are six times more likely to do the same. Whatever the association here, it is more likely a learned behaviour than a genetic association. Once the person develops the habit, it becomes a destructive cycle where pain seems to make it more desirable for the sufferer to continue parafunctional habits.
Treatments for TMD: Now that we have looked at the diagnosis and some of the causes of TMD, lets look at some of the treatments available to us:
AWARENESS. Although some have coined the term 'COGNITIVE AWARENESS', simple awareness and the attempt to consciously alter parafuctional behaviour has been credited with 20-30 % improvement in some instances. This is most useful during the daytime. In some instances, people have placed an elastic band around their wrist and whenever it has caused mild irritation, they immediately focus on their jaws. 'LIPS TOGETHER - TEETH APART' is the common mantra at this point. Believe it or not, this actually works. Other useful ways would be to use some kind of alarm system (e.g. wrist watch) which reminds the patient every hour to be cognizant of their jaw position. Interestingly, one of the tools with the greatest potential for behavioural modification with respect to TMD is the biofeedback machine. Commonly used by psychologists, electrodes can be placed near the muscles and give a biofeedback alarm during muscle activity. Although this sounds fantastic in theory, its lack of practicality has made this less than useful.
SLEEP (DSP) MODIFICATION. This is a 'biggy'. Although it sounds simple in theory, it is very difficult to change people's habits. Consider the following factors in changing sleeping patterns.
In addition to the above, some psychologists have recommended simple tricks which may help a person have a better sleep in general. Some of the self-help books on the market can be quite useful as well. Some things to remember might include:
PHYSIOTHERAPY, MASSAGE THERAPY AND CHIROPRACTIC TREATMENTS. In some instances, one or more of these treatment modalities can be very helpful in improving any back, neck, hip or shoulder problems that might be affecting the way you sleep. In addition, they may help you change your posture (limb length discrepancies are not uncommon), your sleeping posture, driving/work postures as well as your head/jaw posture.
MEDICAL TREATMENT. Occasionally, after hip replacement or shoulder surgery, the patient may return to a better sleeping position.
DENTAL TREATMENT. In addition to the above modifications, there are several effective treatments we can perform to help relieve TMD. Above all, you must realize that we cannot TREAT your TMD, but only alleviate it. What we are saying is that the cause of TMD is rarely dental in origin. In most cases, stress reduction and behaviour modification would be the true treatments. Nonetheless, it is still necessary to treat the dental effects of TMD. These treatments might include the following:
Important Note for TMD patients about to receive dental treatments: There are occasions when patients with TMD will have difficulty,
pain and jaw discomfort during dental treatment. This is not actual discomfort
from the procedure itself but rather pain due to muscle spasms as the
jaw is maintained in an open position during treatment. This usually
manifests part way through an appointment when the patient starts to
rub/massage the jaw muscles. During the appointment, the muscles become
continually more sore and overall discomfort increases, making it difficult
to finish the appointment.
We hope you have found this information useful. If you have any further questions, please do not hesitate to contact us by or by phone (604.224.2411). If you know other people who may be suffering from TMD, please feel free to send this informative page to them. Many people may complain of these symptoms or believe they have migraine headaches without knowing they have TMD. |
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