Dr. Laura Bowdoin is a triple-board certified doctor committed to providing every patient with compassionate, quality care for bite corrections, teeth alignment, and relief from headaches, facial pain, and neck pain. We also offer cutting-edge alternatives to CPAP therapy for Obstructive Sleep Apnea using customized oral appliances and minimally Invasive Laser-Assisted Uvulopalatoplasty.
What is TMJ/TMD?
The temporomandibular joint (TMJ) is the joint connecting the lower jaw (mandible) to the skull (temporal bone). The lower jaw and the skull are connected by a number of muscles and ligaments, which function in harmony with each other if the lower jaw is in the correct position. The head of the jawbone (lower jaw) is called the condyle and it fits into the concavity of the temporal bone called the glenoid fossa. The TM joint resembles a ball and socket with the round condyle being the ball and the glenoid fossa of the temporal bone being the socket. For normal joint function to occur, a piece of cartilage called an articular disc act as a cushion or shock absorber between the two bones.
Symptoms which are collectively known as Craniomandibular Dysfunction are: headaches, neck aches, ringing in the ears, stuffiness in the ears, ear pain, pain behind the eyes, ear pain, shoulder and lower back pain, dizziness, fainting, difficulty swallowing, and tingling of the fingers and hands.
When the lower jaw opens and closes, the disc stays between the condyle and the glenoid fossa of the temporal bone at all times. When this happens, this is a normal healthy TMJ, and the patient can open wide without any discomfort and without any noise. With a normal opening, the patient should be able to get three fingers between the upper and lower front teeth when the mouth is open as wide as possible. In cases where the TM joint is functioning normally with the disc in the proper position, the muscles of the head, neck and shoulders function relatively pain-free.
What is TMD?
Temporomandibular Dysfunction (TMD) is the condition referring to a joint that is not normal.
The position of your teeth can affect the position of your jaw joints. Each jaw joint is like a ball and socket joint. When functioning properly, the ball and socket do not actually touch because a thin disc of cartilage rides between them. The disc acts as a cushion and allows the joint to move smoothly. Each disc is held in place and guided by muscles and ligaments.
What Causes TMD?
The temporomandibular joints are among the most utilized joints in the body, due to their prolonged use during chewing, talking, singing, yawning, etc. Usually trauma is the most common cause of TMD. Macro-trauma like a car accident (whiplash injury) or a repetitive micro-trauma like clenching and grinding (bruxism) your teeth can cause inflammation in the TMJ.
An overwhelming majority of patients who sustain whiplash injuries in motor vehicle accidents (MVA) also dislocated one or both temporomandibular joints at the same time without having impacted their face or head against the steering wheel, door column, windshield or other parts of the car.
Whiplash typically occurs if the head is thrown backward and forward while riding in a car that is hit from behind or the side. Extensive research has well documented the fact that most flexion-extension injuries occur following what is called “minor head injuries.” This means that it is not necessary to suffer a fracture or even a direct head impact. In fact, most patients report that their head was simply snapped backward and forward or side to side. This motion causes damage to the muscles and ligaments which support the jaw joint. When these muscles and ligaments are injured, this can cause an anterior displacement of the protective disc and result in a dislocated jaw joint on one or both sides.
A severe blow the head or the jaw can cause the disc to be dislocated due to the force of the impact on the jaw. Patients may experience swelling, limited opening and clicking in the joint. Patients with this acute injury should seek emergency treatment immediately to avoid further damage to the joint. Obviously, the sooner the patient can be treated, the higher the success rate.
Unbalanced muscles can be a result of clenching or grinding of the teeth. If a muscle is overworked or becomes fatigued due to a structural imbalance, other muscles must compensate. This compensation causes the body to adjust to an abnormal postural state. Compensation means the body adapts to a state that is unhealthy. Severe clenching and grinding your teeth for years can place excessive load on the joint, exhaust synovial fluid lubrication and may cause TMJ inflammation.
Displaced disc, a dislocated disc, unfavorable head posture or body posture and spastic muscles can all refer pain into the neck, face or head.
Muscle tension headaches can be so severe that they are confused with migraine headaches. Unfortunately, patients are often not examined for TMJ disorder, and the “migraine” treatment works poorly.
The treatment for patients with migraine headaches is often a prescription of Imitrex. This medication is ineffective in solving problems relating to dislocated jaw joints (TM dysfunction). Patients are advised to call our office and set up a consultation to determine if your symptoms are due to TMD.
Predisposing factors that make you more prone to TMD:
- Narrow crowded upper jaw
- 5 or more missing back teeth
- Deep Overbites
- Upper teeth tipped inward
- A lower jaw that is too far back
When the lower jaw is too far back it can presses on the nerves and blood vessels at the back of the socket and causes pain. When nerves and blood vessels are compressed, the whole structure is unbalanced, affecting the nerves, the ligaments and the muscles of the head, neck and face. This can cause ear symptoms like tinnitus and stuffiness due to the compressed posterior joint space.
Usually, the protective disc (cartilage) is displaced forward and no longer serves as a cushion between the condyle (lower jaw) and the bony socket (skull) and eventually this can lead to the condyle rubbing against the bony socket. This can cause degenerative changes in the joint complex.
When the disc becomes displaced, this is what causes the various noises within the jaw joints such as clicking and popping sounds. Patients must be aware that any noises or pain that occurs during the opening and closing of the jaw is an indication that the jaw joints are not functioning properly. Patients are advised to seek treatment as soon as possible, acute treatment is less expensive and treatment time is usually shorter than for a chronic condition
More severe displacement can be very painful and eventually can cause permanent damage to the joint.
The etiologies of craniofacial pain disorder are often multifactorial. Dental causality is considered, but so should postural problems (especially of the head, neck and upper quadrant), psychological components, endocrine dysfunction or disease, airway compromises, genetic tendencies, pharyngeal dysphasia and other related problems. In short, these dental, structural, chemical and emotional factors may be considered as part of a thorough evaluation.
Evaluation for TMD
Our office has the knowledge and experience needed for proper, thorough diagnosis and treatment of temporomandibular joint dysfunction. The term craniofacial pain will be used as the collective term for extracapsular disorders of the craniofacial region as well as intracapsular disorders of the temporomandibular joint (TMJ).
Discussion and limited examination take place at the initial consultation appointment. The patient reports time of onset, duration and intensity of pain in the affected area. The examination explores the pattern of jaw movement to detect sounds and tenderness to gentle pressure. A Working Diagnosis will be formulated and any recommended further testing and treatment will be discussed.
Further diagnostic testing is indicated when the presence of jaw joint dysfunction is suspected. Further testing is designed to formulate a definitive diagnosis and treatment plan. These tests include:
- Full Medical and Dental History as well as an examination of the teeth and the dental arches
- TMJ Health Questionnaire
- A complete collection of data used to assess the chronicity and severity of the chief complaint.
- Range of Motion testing using computerized magnetic jaw tracking
Patients are checked for how wide they can open, slide left and right, move the jaw forward, and whether there is a deviation or deflection of the jaw upon opening. We determine how fast the jaw moves during the opening and closing cycle and precisely where the joint noises (dysfunction) occur. If there is a problem achieving normal range of motion and velocity, there is usually a structural problem within the joint.
It is important to assess the posture of each patient to determine whether the shoulders, pelvis, and hips are level. Photos are taken of each patient to check for the above as well as to check for forward head posture. If there is a problem with the shoulders, hips or pelvis or if one leg is longer than the other, then a referral to a chiropractor or physical therapist would be necessary.
Full Muscle Palpation Exam
Excessive muscle contractions and trigger points indicate a problem with the chewing muscles of mastication. This causes the muscles of the head and neck to be sore when pressed by the doctor. This usually means that there is an imbalance and dysfunction present.
TMJ x-rays are important to see if the condyles (top of the lower jaw bone) are too far back where they would be impinging on the nerves and blood vessels at the back of the socket where the jaw bone fits into the skull. We use 3-D Cone Beam Radiograph (CBCT) to determine condyle position and any degenerative changes in the TMJ.
Joint Vibration Analysis (JVA)
Joint Vibration Analysis (JVA) provides a fast, non-invasive, and repeatable measurement of TMJ function to aid in diagnosis of TMJ function. Human joints have surfaces which rub together in function. Smooth, well lubricated surfaces in a proper biomechanical relationship produce little friction and little vibration. But surface changes, such as those caused by degeneration, tears, or displacements of the disk, generally produce friction and vibration. Different disorders can produce different vibration patterns or “signatures”. PC-assisted vibration analysis helps identify these patterns and helps you distinguish among various TM disorders. The JVA is simply a 3-minute, non-invasive test where headphones are placed on both jaw joints and the patient is instructed to open and close about six times.
A psychosocial screening is often of value for the craniofacial pain patient.
The TMJ scale is used for the pretreatment assessment of the craniofacial pain patient as well as a means of assessing treatment progress and treatment outcome. The test is completed entirely by the patient, thus eliminating subjective clinical bias and allowing cross practice comparison of TMD symptom severity. The TMJ scale is supported as a psychometric assessment tool and by a large body of published validation data. The tests assesses clusters of physical symptoms including joint dysfunction, pain, range of motion limitations and psychosocial symptoms including stress, psychological distress and predicts overall clinical significance of a craniofacial pain/temporomandibular disorder.
Cranial Nerve Evaluation
Because of the strong interrelationships of the 12 cranial nerves and the multiple signs and symptoms exhibited in craniofacial pain disorders, this evaluation and its subsequent findings will lead the doctor to definitive diagnosis.
Treatment for TMD
Since the teeth, jaw joints and muscles can all be involved, treatment for this condition varies. The goal of treatment is to relieve the muscle spasm, inflammation and pain as well as establish proper joint position and normal range of motion with function of the lower jaw.
This is accomplished with orthopedic appliances that cover the teeth. Some patients need to wear their appliances only at night and others need to wear the orthotics 24/7 to stabilize and decompress the jaw joint.
The orthotic covers the teeth holding the jaw in proper alignment, reducing tension in the muscles of the jaw joint, allowing healing to take place. Once pain is controlled and the jaw joint is stabilized, the bite is balanced so the teeth, muscles and joints all work together in harmony.
Objectives of the TMD orthotics are to try and establish the correct position of the mandible to the maxilla in three dimensions; transverse (side to side), sagittal (front to back) and vertical (up and down). The goal is to try and find a comfortable position for the lower jaw so that the patient can get some relief from the pain and muscle spasms. The orthotics also positions the condyle in the proper spot inside the fossa.
Since most head, neck and shoulder pain originates from muscle instability or swelling and inflammation of the joints, we may employ various physical medicine modalities to treat and help normalize these structures. These include; moist heat therapy, vapor coolant spray/stretch, ultrasound, cold lasers, electric stimulation of muscle trigger points, trigger point injections and MCP (Micro-current Point Stimulation). These joints often get very tight in people with dysfunctions and various types of mobilization or stretching techniques are employed to gain normal function of these tissues.
Other treatment options for Temporomandibular Dysfunction and Migraines is Botox injections. Our office offers the use of botulinum neurotoxin (Botox/ Xeomin) and dermal fillers for not only dental esthetic but therapeutic uses in the oral and maxillofacial areas. These uses include treating dental and facial esthetics for volumizing nasolabial folds, marionette lines, lifting up the corners of the mouth using anatomical landmarks, smoothing lip lines and eliminating vertical “smokers” lines, and treatment for bruxism to relieve TMJ syndrome, headaches, migraines, and bruxism.
Sometimes it will be necessary to refer patients to other health care practitioners to help relieve some of the muscle spasms including chiropractors, massage therapists, physical therapists, SOT therapists, etc.
The patient must be made aware of the fact that, although the majority of patients do improve substantially, there are still a small number of patients whose do not respond to treatment. After conservative treatment fails referral to other healthcare providers is warranted.
Here are a few questions you may want to ask yourself, to help determine if you have any symptoms:
- Do you get an unusual amount of headaches? Y N
- Do you have a grating, clicking or popping sound in either or both jaw joints, when you chew or open and close your mouth?
- Do you have pain or soreness in any of the following areas: jaw joints, upper jaw, lower jaw, side of neck, back of head, forehead, behind the eyes or temples? Y N
- Do you have sensations of stuffiness, pressure or blockage in your ears? Y N
- Do you ever have ringing, hissing or buzzing sounds in your ears? Y N
- Do you ever feel dizzy or faint? Y N
- Do your fingers, hands or arms sometimes tingle or go numb? Y N
- Are you tired all the time, fatigue easily or consider yourself chronically fatigued? Y N
- Are there imprints of your teeth on the sides of your tongue? Y N
- Does your tongue go between your teeth when you swallow? Y N
- Do you have difficulty in chewing your food? Y N
- Do you have any missing back teeth? Y N
- Do you clench your teeth during the day or at night? Y N
- Do you grind your teeth at night? (Ask your family.) Y N
- Do you ever awaken with a headache? Y N
- Have you ever had a whiplash injury? Y N
- Have you ever experienced a blow to the chin, face or head? Y N
- Have you reached the point where drugs no longer relieve your symptoms? Y N
- Does chewing gum worsen your symptoms? Y N
- Is it painful to stick your “pinky” fingers into your ears with your mouth open wide and then close your mouth while pressing forward with your “pinky” fingers? Y N
- Does your jaw slide to the left or right when you open wide? Y N
- Are you unable to insert your first three fingers vertically into your mouth when it is open wide? Y N
- Is your face crooked and not symmetrical? Y N
- If you answered yes to some of these symptoms, you may have a TMJ disorder (TMD) Call our office for a consultation.
- Here are some ways you can visually check your TM joint:
- Put your fingers inside your ears. Open and close several times. If the jaw clicks or cracks, or if you feel a grinding sensation.
- While looking in a mirror, open very slowly, notice whether or not your jaw swings to one side while opening and closing. Is there any pain present?
- Slide your jaw from side to side, make note of any pain you may experience.
- Check for muscle sensitivity:
- Place your fingers in front of your ears on the joint and apply pressure.
- Also apply pressure to the cheek area
If you notice discomfort or pain during this self-assessment, please call our office at Leawood Office Phone Number 913-258-8028 for our Leawood office orLouisburg Office Phone Number Louisburg Office Phone Number 913-214-0205 for our Louisburg office, schedule your consultation today.
Disclaimer: Content on this site is to be viewed as educational only. In no way should content be taken as formal medical advice