Diagnosis and Treatment of TMJ Disorders

welcome to the Stanford health library thank you for coming here tonight my name is Michelle Johansen and I work at the oral facial pain clinic at the Stanford Pain Center in Redwood City so today's topic is TMJ disorders TMD I'm going to speak about the nature of the disorder what a TMJ disorder really is I'm going to also talk about who is at risk for TMD and finally I will touch on the common treatments that are recognized as evidence-based treatment for TMJ disorders so I I guess it's customary to talk about disclosures as to if I'm affiliated with any kind of pharmaceutical company or anything like that I have no disclosures to be done so I wanted to first show you the anatomy of a TMJ it's a joint that is very unique in the body it's one of a kind there is a one disc and you can picture it as a doughnut so it's it's it's a circular by concave just a doughnut just doesn't have the actual hole in the middle so it's kind of like a doughnut shaped and it separates the jaw bone which you see as the rounded bone in the picture from the skull and particularly the fossa the articular fossa and the eminence that you see to the right of the fossa so the disc is it's flexible its fiber cartilage and it offers a perfect interface between the skull and the jaw and it allows for a smoother motion the joint is also particular in the sense that not only it allows rotation of the joint but it allows for forward motion of the jaw so if you put your hand like slightly over your in front of your ear and you open your jaw wide and slow you can see that initially it just starts rotating and then you can feel it actually advance forward and for some people you can actually feel it coming out slightly because even though the jaw is seemingly fixed the suture that is in the front it allows for certain flexibility in and out of the joint itself so what is a TMJ disorder so a TMJ disorder is defined by pain either at rest or upon function it is defined by something that is painful noise it can also be just a dysfunction like a limited range of motion or a jaw deviation such as this like when you open you go to one side or you you are unable to go from one side to the other or a sudden unexplained by change like you wake up and you joy's to the front or to the side those are considered TMJ disorders they can be associated with headaches and ear aches or ear pain so the the prevalence is six five to 12% the vast majority of them women and the age group is between puberty and menopause and there's some research suggests that they're so linked with hormones as the cartilage in the TMJ has estrogen receptors so that's that would make sense since the age group is you know few ready to menopause so that leaves us to what is not a TMJ disorder and it's pretty obvious if there is no pain no dysfunction dysfunction is if you're able to open your mouth wide if you're able to chew without pain you don't have a TMJ disorder you may have noises you may have joint noises but you do not have by definition a TMJ disorder you can have abnormal abnormal findings in an MRI or an x-ray without having a TMJ disorder there are a lot of people and certainly most of us over 40 will have some type of changes on an x-ray even though we are still completely asymptomatic and we can chew and we can open our mouth without any restrictions so that's a that's kind of a something that comes up a lot I mean I get patients who come in because they have joint noises because they have been told by their dentist that they had a TMJ disorder or because the dentist saw on the x-ray that there was something abnormal so of course we can determine it but by as a rule of thumb if you don't have any pain or dysfunction you don't have a TMJ disorder you don't have to worry 60% of people pop and click so it's a very common incidence they don't really consider it a disorder because it's a variation of normal at this point I will come back later about the popping the mechanism for popping and clicking but I want to touch on remodeling of the TMJ which sometimes occurs on extra or in the sea on the next day so if you look at this x-ray the TMJ is right this is one TMJ this is the other TMJ right right and left so it should be kind of rounded and it should have a continuous white line around it and you see here it is a little bit flatter on the top but it has a white line around it so when it has a white line around the perimeter of the condyle it's considered remodeling and remodeling is a process of bone changes and the bone is a dynamic structure it's not like there to stay like for example if you've ever had braces what allows the teeth to move is actually the bone remodeling on one part on one part you have some bone destruction that allows the tooth to move and then the bone rebuilds on the other side – so it's a completely normal and natural phenomenon to a certain extent so if it's slower if it's a slow process and if it's an adaptation process its its normal and it doesn't give people any trouble whatsoever so this is considered a very normal cone beam CT scan of the jaw which doesn't mean the patient is asymptomatic they can have pain with a normal x-ray and that's the thing that's the other thing you can have absolutely no pain with a terrible looking x-ray and we can have pain with a normal x-ray so what types of TMJ disorder are there well we classify them as TMJ disorder disorders involving the muscles of mastication involved the involving the joint itself or part of a systemic disease so the muscle disorders are for the TMJ and the muscles of mastication are just exactly the same as for any muscles in your body there is muscle ache restriction of range of motion fibrosis tendonitis you know you've had some people with tennis elbow you can have tendonitis of the jaw as well so the muscles of mastication and you can feel those as well are usually for the most part the masseter and the temporalis muscles those are the ones that give people the most trouble so if you feel right here and you put your teeth together and then you clench really hard you will actually feel above and that is your masseter muscle if you put your hands up here by your temples and do the same motion you can also feel a muscle bulge and that's the temporalis muscle it's a fairly thin muscle but very very wide both of these muscles help to bring the jaw closed so a lot of patients who come to our practice myalgia or myofascial pain in the temporalis muscle and I mean a temporalis muscle sorry or the masseter muscle and that translates into very often a limitation of their range of motion they cannot open their mouth really wide or they develop pain so that's a very common common TMJ disorder medial pterygoid is the one that is the mate if you wish of the masseter muscle but on the inside of the jaw and the lateral pterygoid is the muscle that allows you to bring you Joffrey's ight to side and bring your jaw forward so it's a tiny little muscle we can't palpate it but occasionally it causes problem even though it's pretty rare then moving on to joint disorders we can have a joint disorder that is directly associated with a disc dysfunction remember that little donut that I was showing you you know it's it's held by ligaments that go and it goes forward and backward so there's a lot of possibilities for things to go wrong as far as this little disc there are there's trauma of course I mean fractures and so on as well as sustainment systemic diseases such as arthritis rheumatoid arthritis lupus and the likes as well as of course I didn't mention this I have some slides on tumors of the jaw so again this is the same slide I never really quite sure how you pronounce this I usually say gently MoIT our throat you'll join which is the type of joint that the TMJ is so it just means it rotates and it slides so the rotation lower part of the car of the joints or the disc with the condyle so the condyle rotates in relationship to the disc and the translation is the whole disc and calm down move forward I tried to find a video but I could only go through YouTube and they mostly dissection videos so I didn't think that it was a good idea this is an MRI picture of the disk if you see a little hourglass darker can you see a little darker shadow in the shape of an hourglass well this is what a normal disk looks and it is held by ligaments on this side ligaments and muscles on this side so it says here it is the same disc but in a more in a mouth that is wider open and you could see that the discus move forward in relationship to this eminence so again this is a closed mouth and this is an open mouth and this is a normal position of the disc and normal position of the condyle so what kind of distance functions are there so we'll start with probably the most common and it is when the disc which you can see here in the picture or here in the model is completely anterior to the condyle if you look back at this one the back of the disc is located it's 12 o'clock in relationship to the condyle on the anterior disc displays it's actually way way way forward and it's impossible for the condyle to get into the middle of this disc it's kind of stuck behind it and so usually it's something that happens very suddenly either while you're eating or sometimes when you're yawning or a pretty abrupt motion and all of a sudden you won't be able to open your mouth it's a very very very sudden event and sometimes it will last for several hours and also it will suddenly get better or you'll have to go to a dentist and help put it back in place so this is that it's a unfortunately this isn't an opening motion so this is a closed jaw and this is a little bit further open but you get the idea right it usually is painful but not necessarily but if you try to open it will be like you're hitting a brick wall I mean there's just no give whatsoever and this is where I come back to the benign clicking that I was talking to you about the benign clicking oh there's a spelling mistake there sorry about that no no no there is no sense okay good good so the benign clicking the clicking that 60% of people have it don't have any problem with it actually one of our camera people showed that to me earlier today how many of you have clicking do you have any symptoms associated with it or do you have just have benign clicking no pain no dysfunction like most people most people have that situation so what it is it's in here as you can see in Figure a the disc is also anteriorly displaced but during the opening motion the condyle is actually able to go past the posterior part of the disc which is slightly thicker to get and fall into the middle of the disc and this is the passing through and over the back of the disc that creates the noise so it's a it's just a functional noise I consider it a nuisance there's nothing you want to do about it there's nothing you should be doing about it no surgeries no treatment whatsoever during the course of your lifetime it might change it might become a little bit earlier I mean a little bit later in the motion let's say when you're 18 it might be really early because the disc is just a little bit anteriorly displaced and then as you get older it might be when you have you only have a click when you open your mouth really wide I only have a now when I yawn but I used to have a clique all the time and it was about very convenient because I could I could demonstrate it to my patients so this is not necessarily going to evolve to a lock for the vast majority of people clicking will never evolve to a lock but it's not nobody is able to predict it this is a another one that people have have probably heard of it is an open lock and it's actually a subluxation of the entire joint in front of the articular eminence and the joint is basically not able to come back over this bump here and it's being stuck because the pull of the muscles are actually maintaining it in that fossa so the more people try to close their mouth the least they're likely to because the pull of the muscle does not allow the job to go back so this is fairly rare but it is an emergency because you cannot eat you cannot you can hardly swallow you cannot talk and it's something that necessitates medical attention to to reduce and usually I don't see those patients because those patients go to an emergency room right away I do see quite a bit of closed lock and unfortunately I don't see them as early as I should and by the time I see them the treatments are more limited but the open locks it's they go to the emergency room and rightfully so this is a posterior displacement with the disk instead of going forward goes backwards this is very rare I've actually never seen a single one and I was unable to find a single picture online but it does happen and in those those situations extremely painful it's a very very painful condition also rather suddenly and it translate the symptoms is that you're no longer able to bite down completely and it's very very painful to try to put your teeth together when we come to arthritis systemic disease and all of them will kind of look like this on an x-ray a lot of degeneration of the bone it's only further testing that will show what kind of disorder it is of course all right osteoarthritis being the most common the great news in terms of the osteoarthritis of the TMJ is that it is unlike osteoarthritis of the knee which is a situation where you have a knee that degrades to the point where you're gonna have to have a joint replacement arthritis in the TMJ is self-limiting and will eventually burn out and the reason for that is that as opposed to the knee that has hyaline cartilage which is a type of cartilage where it doesn't have any kind of blood supply in it the TMJ is covered with fiber cartilage and so the fiber cartilage will regenerate the jaw will never look normal because the bone is gone but a layer of cartilage will reform over the joint and eventually people with osteoarthritis of the joint will be able to function without pain and fully like like before so that's a great thing to tell patients who are pretty scared when they see their x-ray and believe it or not an x-ray a really terrible x-ray can be seen in 16 year olds and when you have a 16 year old they come in and with their parents usually and they're told that they had arthritis it's kind of a it's not a good thing but if you tell them that eventually they will be okay it's a lot easier to have a conversation so this is another one of those x-rays and the difference between this one and the one that we saw before where there was just remodeling is that if you look instead of having the line that goes all the way around just like on view for example on this view it's the way we want it but on some of the views you can see there is a little bit of shadow there's not quite a line here same thing here we lose the line at this point in the image and that's the sign that there's an active process happening that's the difference between the remodeling and the active joint degeneration so this is a terrific image it's totally underused it's called it's called a cone beam CT scan it's available in some of the dental offices and EMTs use it as well because you have a pretty good view of the sinuses and oral surgeons use it but it's a lot less radiation than a regular medical CT and it gives us such a better image of the joint so this is another picture of the generation this is a 23 year old I mean this 23 year old has lost so much Anatomy you see it's really flat here and it's really flat here as opposed to the rounded curves on both the eminence and the condyle I mean for 23 year old that's pretty dramatic I have a couple slides of tumors this is an osteoblasts Toma this is of the jaw it's pretty obvious on x-ray as well usually a very slow-growing these are more this is from the condyle you see that bulge here and over here you have a cyst so all these are benign these of this this one is Wendy the first one was not but this these two are benign and usually unless they interfere with function if the patient can open and close we leave them alone and watch them but that determination has to be done on a case-by-case basis and the one thing you wanted do is eliminate the malignancy you want to make sure the tumor is not malignant other than that you know you want you just watch it so that comes to the really really interesting and controversial question of what causes a TMJ disorder and there's a lot of debate about it because in the even within dental professionals I mean when I was in school I graduated in 1988 they they were teaching us that TMJ disorder was due to a bad bite and that the treatments for TMJ disorder was to make the bite the perfect bite or improve the bite I mean that was 30 years ago you know so it definitely has changed since then and even in the dental community some people are still adhering to principles that are no longer based on evidence and certainly that assumption that it's not I mean the the fact that it's not caused by a malocclusion or about by it has been studied it has been studied and the results are very clear and very consistent because they have studied people a group of people who had perfect bites and no TMJ disorder they created some interference they so they changed their bite so that they didn't have a bad bite anymore and they left them like that for six months and they came back and they still didn't have more TMJ disorder than the general population conversely they took people with TMJ disorders and a bad bite and they corrected their bite and they followed them up and so there's no relationship with so people who say that you need orthodontics to cure TMJ it's just not based on evidence and unfortunately that is done pretty commonly in certain circles and of course in academics we don't do that but that's something I want my patients to be aware of because that's a very costly proposition of course you know if you have to have braces or another thing that we we know is that of course blunt-trauma fat fractures motor vehicle accidents they can cause a TMJ disorder right however I have seen patients with fractured condyles at a 90 degree angle who came to my office sent and referred by their dentist who had seen the x-ray and the same patients had no dysfunction no pain so it's very variable as far as presentation but definitely you can say micro trauma blunt trauma can cause a TMJ disorder micro trauma or load is what we always traditionally thought caused a treat TMJ disorder micro from our load would be grinding clenching going to the dentist having surgery long openings yawning chewing hard foods traditionally especially grinding and clenching were associated with TMJ disorders and I'm going to come back to that particular that particular item in a little while persistent pain is also an ideology and persistent pain is more there is no finding on an x-ray patients just have pain and those types of patients are more in the spectrum of fibromyalgia IBS chronic migraines and TMJ disorders fall in that same spectrum so there is a pain issue that is central that is brain driven that is definitely not due to peripheral component such as the bite or even grinding or clenching and disease process that's pretty obvious that's the arthritis and the lupus and so on and so forth that's pretty documented now if you look at micro trauma or load you know the question now is what kind of importance does a load have for patients who have a TMJ disorder or have propensity or or at risk for TMJ disorder is it more like an aggravating factor for some people who are just already susceptible is it a perpetuating fact that once you have it you don't heal it's said there's a lot of research and there's a lot we don't know about the origins or why some people develop TMJ disorders and why others don't 60% of the people or 50% of people clench and grind in the population at night that's something we humans do it's it's it's controlled by our brain it's no longer believed to be brought about by stress it can fluctuate like daytime clenching and bruxing in grinding yes stress may be involved in it but nighttime bruxism and clenching are no longer believed to be associated with stress that's something 50% of people do and in the population 50% of people don't develop TMJ disorders so there's not a direct correlation with load and TMJ disorder and so we're looking at other things that could potentially differentiate the people who develop TMJ disorders and the people who don't develop TMJ disorders given that both of them grind and clench so what are we looking for so we're looking at symptomatic and asymptomatic patients patients with pain patients without pain and we look at patients who have the same Anatomy the same maybe we look at a population of people with a displaced disc and pain or people with myalgia and we look at their genetics we look at the grinding and clenching they do their anatomy and we try to find something that differentiate both groups of people and is very difficult because there's so many variables but the one thing that has been studied right now is adaptability and resilience and so adaptability is kind of the ability it's genetically determined but it's the ability of our body to heal themselves so you can have for example somebody that will lean more to its what we saw there as you know where the x-ray was remodeling but no evidence of disease well for some people they will respond to load with adaptation and other people will respond to load with degenerative joint disease so there's something that's genetic and it's a risk factor that we can't really control there is and there is an evidence that there's a relationship between arthritis and displacement of the disc now is the person who has arthritis at risk for this displacement or is the person that has this displacement more at risk for arthritis so we haven't figured that one out yet so basically when the patient comes in we treat the symptoms we can't really treat the cause so adaptability is a big one and it's it's it's a that we can observe we can observe that some people because of the x-ray for example we can observe that some people do not degenerate some people's joint do not degenerate but then you know we look at so this is what we're talking about you have the anatomy in the load when it's not really great you have pain adaptability is the factor that can be the difference between the people with symptomatic not symptomatic but then we also have situation where we have similar seemingly the same adaptation there's nothing on the x-ray that's particular nothing out of the ordinary in terms of load no seemingly trauma no dysfunction particularly and the patient is in pain so we thought okay maybe their load is bigger you know that's a possibility maybe they grind more maybe they clench more who knows right but we also looked at something that's called resilience and resilience is an ability that is sometimes innate that we have to cope with certain dysfunctions and pain that makes it that we experience less pain and dysfunction so we started looking at the resilience and that's the studies that are done mostly by pain psychologists on pain patients on chronic pain patients see usually people who have good adaptation and resilience when they have a certain amount of disease they seem to respond better to treatment the treatment that we do it works and then sometimes we do the same treatment on seemingly the same time a patient and it doesn't work and that's puzzling and frustrating for us providers of course and so we want to have more research so this research on reliance and adaptability resilience inland adaptability has led to this kind of schematic you know when you have you know the TMJ pain or dysfunction and you have several areas that can influence positively or negatively on the outcomes so the load is obvious the anatomy is obvious genetics and adaptability we can't do anything about so we have to look at okay sometimes this was the old way we looked at TMJ disorders it had to be the load it just had to be the load they did not consider these two factors so once we started opening our mind a little bit out of the box then we bring in these two conditions other pain conditions because it's well known that if you have other pains in your body if you have chronic pain in your leg chronic pain you back chronic migraines and then you develop TMJ disorder you will perceive that as worse I mean that's just the way the brain works once you have pain the brain signals can just free flow a lot more than if you don't have any other Payne condition so we can think that there are other pain conditions we can think that the resilience is less we can think that maybe it's a combination of other pain conditions being interfering and a lack of resilience so there's a lot more treatment option and treatment possibilities that open up this is how we all would like to be able to treat right you have the symptoms you take a test you figure out what it's caused by and then you get a treatment that works I mean that is the simple equation that we sometimes can do with some disease but with TMJ disorders it's just it's just not like that and that is the hard part for patients alike and provider patients and providers alike is that there are people who come in with exactly the same symptoms you give them the same treatment and they have different outcomes so that that is very very difficult so adaptability seems to have more to do with the body's ability to cope and the resilience with the minds ability to cope and because a friend of mine psychologist was had a very simple equation she would say pain is and that is actually based on the definition of pain if you go to the dictionary and you look at pain it's not only a body perception but it's also an emotional component and so the emotional component is just as big as the actual perception of the physical pain so if you can reduce either the emotional portion or the physical punch portion of the pain you can actually decrease the overall experience of pain that the patient receives and that's that's a really big new approach for chronic pain that we've been practicing at the Stanford pain clinic is that we don't just think that pain is a bodily perception we also feel that the emotional distress associated with both the pain the disability the dysfunction is just as important and it's the sum of these two that can make the patient more or less miserable so if you think about it that way you get better outcomes unfortunately Dennis just by our training we are used to do things right you see you cavity you drill a hole you fill it problem solved so Dennis tend to need to do something they don't usually just there are situation where it's better to do nothing you know so Dennis starts by training they're used to actually do procedures make appliances equilibria the they have a drill they want to use it so it's it's a it was a different it was an actual different frame of mind that I had when I went to my residency it was a totally different frame of mind to come back more to a medical model so this is the way we used to treat TMJ disorders first line two we have the first line treatments anti-inflammatories corticosteroids physical therapy for the muscles no trigger point injections if necessary joint injections if necessary joint manipulation you know to reduce the joints I mean not chiropractic manipulation but if the joint was locked we manipulated them open and as an adjunct we used to have moist heat meditation relax bro so relax and pain psychology rarely surgery even though twenty years ago it was very very in vogue and a lot of people used to have joint replacement surgery that has really totally totally been discredited joint replacement surgery is very very rarely indicated maybe in case of trauma or cancer yes but the results were so disastrous that they're done not really very rarely open joint surgery again I mean some people had surgery for clicking benign clicking and ended up crippled you know not being not able to open their mouth so it's very very sad but I still see them you know so some reason some people still have surgery and never orthodontics bite adjustment and opioids we don't really use opioids it's not a disorder that necessitates opioid treatment the chronic disorders don't really do anyways but even acutely it's not usually the type of pain that necessitate opioid so now that we know all this about adaptability and resilience we are moving this whole category into a first-line treatment so we have pain psychologists that will work on patients and give them better resilience resilience is something that some patients have on their own they have those coping mechanisms they were born with them or they acquired them along the way but you can teach them you can teach them to people and that's what the pain psychologists do they teach patients coping mechanism they increase their reliance their resilience they D keep the decrease their focus their catastrophizing catastrophizing is is is a feeling that you have that your disorder actually is very very bad it's not benign it's going to deteriorate it's so it's like a doom and gloom approach to two disorders and certainly in the TMJ world there's really no need Dumon for doom and gloom so they do lifestyle modification relaxation meditation also works quite well even though you have to practice that and there is more recently there's some more emphasis on sleep and sleep quality than there was before there's some research that show that if you have poor sleep you will tend to Brooks grind your teeth because you never get to the very deep sleep for some people who wake up a lot they never really go into the deep sleep where the muscles are completely paralyzed and so that might affect their adaptability or their resilience so anyways the resilience definitely because people who don't sleep well you can ask universally if a patient has chronic pain if they're more stressed the pain will feel more if they don't sleep well the pain will appear more worse so it's it's not that necessarily stress is inducing the pain it's more that when you have stress you're paying highways or you pain processes are different and so that's where working with a pain psychologist is for us and valuable and that's why going to a pain center like Stanford that has the pain psychologists available is it's a real bonus I mean I've worked both with and without pain psychologists and I cannot tell you the difference that it makes for the outcomes so I will finish my talk here to leave some room for questions and answers because it's such a difficult subject in terms of if you have been affected by the disorder you probably go to some to a physician or a dentist and get like five different options or you look online and you have these multiple opinions of what you should be doing the one thing that I have to say and this is really pretty important is that all the treatments that are done for a TMJ disorder all the treatments are reversible so things like full time wear splint it's it's it seems really benign but full time wear of splints can change your bite in a permanent way so if you wear split and day and day out for several months your bite will most likely change and what you do at that point that you need braces and some people actually have a phase one phase two process where they change the bite on purpose with the use of a full time appliance and then afterwards they restore the bite to a better position so stay away if I can give you one recommendation is stay away from treatments that cause that are not reversible so in the in the non reversible one you have orthodontics full time where if splint bite adjustments and everything else you know there are a lot of things that work I mean acupuncture might be a wonderful treatment for some people other people will respond to muscle relaxant some other people don't want to hear I mean there are a lot of options of treatment it's not like everybody that gets a TMJ disorder gets exactly the same treatment we discuss with patients what their preferences in terms of of treatment philosophy and if they want to see a pain psychologists and work on meditation and relaxation first it's fine with me you know and depending on what they have things like antidepressants topical or oral work really well for things like inflammation just like in other joints of the body but please reversible is what I would like you to bring home from this lecture so I would welcome questions on any part of the speech or on other things you may have read online yes understand do you feel that once that what we used yes the question was do you feel like splints are overused okay in general I really believe so and the reason being that there is in dental school we get no training we have no training in TMJ disorders so most of what dentists pick up to treat patients is over the course of you know here and there continuing education they learn how to make a splints and so Dennis basically the only thing that they know what to do is to make splints so that's usually the first thing they try they say okay we'll make you a splint and if it works great if it doesn't work well I'll send you somewhere else so probably 70% of people who come to my practice have gotten a splint from their dentists I would say that most probably realistically only 20% of people with TMJ disorders would need a splint or would benefit from a splint it's a very difficult question because they have tried to do a lot of research on splints and there wasn't really a particular type of patient that is ideal for splints like some people respond all over the place like 50% of people with respond 45 will not 5% will get worse and we cannot pinpoint which ones are the ones that get better overall for me in my practice if I have a patient who whose pain is worse in the morning when they get up I will try a splint if they're worse in the afternoon and they have no pain in the morning I'm just assuming that they're not doing anything at night that aggravate their disorder so I don't really believe that the splint will do anything I will use a splint if they grind their teeth to protect their teeth because that we know the splint does but what the splint actually does for patients in pain is is unknown and there's certainly people out there and with with good backgrounds very reputable people who believe that part of the benefits of this plane is placebo which you know placebo is not all bad no placebo I mean 20 percent of any treatment that I do patients including medications that have research backing it is placebo yes a splint and I I should have taken a picture of a splint it's basically a night guard have you do you know what a night guard is a night guard is a piece of plastic that is molded to your teeth and that is acting as an interface between it I should write it goes either on the bottom teeth or the top teeth and it's basically a plastic interface between the the top teeth and the bottom teeth and it's called a splint it's called a night guard is called an orthotic it's got various various names splints you know if if to me it's in the category of it's pretty benign as long as you don't use them full-time and certainly for some people they do work so in some patients I think it's worth it's worth trying I like them to be full arch I do not like the one that only are in the front teeth they were marketing they're called NT eyes and they fit just in the front teeth and they were marketing them for grinding because they they said that if you clench on your front teeth you don't clench as hard which is kind of true but you clench enough to get by changes and so the research on those has been pretty bad in terms of reversibility so I don't use those I use the full full arch splint that covers all the teeth more like a retainer like an Invisalign retainer except thicker and again people do thick splints thin splints hard splints splints and a lot of people swear by the splints they make but if you look at the research there's really no type of splints that works better than the next so whatever your dentist wants to make if they are into hard splints by all means heart splint is fine if they want to do soft splint it's fine – it's just more like is it comfortable for the patient does the patient like it better yes well yeah it's it's not really so much as it I put in there in the AB junk okay so adjunct it's not really a first line I will try other things but if the patient continues to have morning pain it's something that is not a medication it's benign and some people find benefits so it's it's still in the range of of treatments that are worth exploring yes if as long as you don't use it full-time and buy worse it is painte just some people develop pain and then you just have to give it away yeah if you wear them if you wear them full-time yes nighttime it can but it it usually doesn't and as long as you check it every day when you wake up make sure that your bite hasn't changed and it's usually fine we have time for a couple more questions yeah yes what it is this if you look it yes the if the I mentioned that the TMJ pain is also sometimes associated or felt as an ear pain it's more because the of the proximity of the TMJ with the ear so if you look in an Anatomy textbook there's just a very thin piece of bone that separates the TMJ from the ear and so because the pain sometimes if it's really intense it expands yeah it kind of gets perceived in this area that's why a lot of people see an ENT doctor first before they see me because they perceive it as ear pain but it's it's not because it is affecting the ear directly no it's more it's more on the inside I mean most people think it feels like an ear infection it fits your mouth the by change is not because the teeth change but because the position of the condyle inside the fossa will change so because of see when you look at the let me put a picture of the of the actual joint okay almost there okay so this is the condyle and this is the fossa when you have a night guard in your mouth you are going to have a different position of this disk and this condyle because the jaw will be slightly more open so the disk will be a little bit more interior and the condyle will be a little bit more interior because of the position of the jaw and if you keep it there 24/7 the soft tissue within the capsule will adapt to that position and it will be difficult to go back to the old position yes it's you if it's just used as a night guard at night in the morning when you take it out I wear one because I wear one as a retainer basically because I had braces so for me a night guard is the right thing I don't know I don't wear it for pain or a TMJ disorder but when I take it out in the morning even though it's very thin my bite is a little bit different because of the muscle position or but that's okay because within five minutes it's it's back to normal yeah yes I used to wear one and I wasn't hard it shouldn't need to it shouldn't it once it's adjusted to comfort and it's symmetrical and it's the same amount of force and you feel like you're biting on both sides in the same way it shouldn't need to get any adjustments I mean you will continue to wear it down but you worry down because of function and so you continue wearing it down until there's a hole in it and you need to have it replaced that's all oh that's when they actually when they actually grind your teeth you know when you don't have a perfect bite you may have a tooth that's a little crooked right or that is a little bit tilted and when you go side to side you hit that tooth first and so they shaved that part of the tooth away so that you can translate from side to side and I say if a bite was if a perfect bite wasn't the solution putting a night guard on everyone should heal everyone because once you have a night guard you have no interferences you actually have a pretty perfect bite because the night guard is adjusted perfectly so the theory that a bite is a determining factor is pretty much obviously not right and during the day you never touch in your teeth together anyways so you function except for when you swallow that you briefly put your teeth together even when you bite on food because food is the interface your teeth are not actually contacting that much and I have seen people with incredibly horrible bites and no symptoms the only time that I would say bye it has an issue is of importance is you have people who lose all posterior support like they lose their premolars and their molars and they they can't they don't have a stable bite so whenever they buy their jaw does this because they have nothing to bite on one side in that instance I understand that the bite should be restored to a stable occlusion but as so as long as you have a stable occlusion which means you buy it on both sides on your back teeth it should be fine yes interesting but were you going to ignore that is correct that is correct and actually orthodontists get a really bad reputation because very often TMJ disorders start at the same time as orthodontic treatment but it's mostly because the onset is usually around puberty which is also the same time as people get braces but some treatments done by the orthodontist can aggravate a TMJ disorders like elastics that bring the job back if you already have a TMJ disorder it's probably not recommended but the bite thing not so much one more one one more question who has an no you haven't said anything yet yeah-oh dental procedure or an appliance or an appliance yes and I'm just wondering okay yeah I am very familiar with the appliance because I make them for my patients with sleep apnea and applies for sleep apnea is basically an appliance if you're familiar with CPR are you familiar with CPR well you know how you do a jaw thrust for unconscious patients to open their airway well basically an appliance brings the jaw forward into a thrusted position to open the airway and have patients breathe better at night so it's an appliance with which the jaw is maintained in a forward position through the night which is pretty dramatic you know and it's done in a very progressive way you know 1/10 of a millimeter time maybe over several months and certainly in those situation you get more chances of having bite changes than with a regular night guard but even in those patients you don't find a lot of bite changes that you see some by change but usually they don't notice it in terms of TMJ disorder bringing the jaw forward slightly if they have a joint disease might not be a bad thing for their symptoms because there will be more space in the joint when the jaw is brought forward but if they have a myofascial issue it will be very difficult to tolerate because the muscles are trying all night long to bring the jaw backwards and so even patients who don't have TMJ disorders or myalgia sometimes gets myofascial pain and pain in the masseter muscles and temporalis muscle initially when they start the appliance but it's a very very well tolerated appliance and it's an alternative to CPAP for patients with mild and moderate sleep apnea well your second question the load is considered any kind of movement that that puts undue forces and loading on the joints so grinding bruxing crunching part foods chewy foods incidentally salad it's very difficult to chew people think oh no problem I don't have to eat hard foods I'll eat salads well salads I have bad news salads for TMJ disorder patients are just the hardest thing to – you learned something and that you are now more able to look at the literature online and and see the good from the bad of the evidence-based from the cuckoo out there it's not a new department per se is it's part of the Stanford pain clinic and so it's in the same building and it was the same Faculty of the pain clinic but it's it's it's an oral facial pain focus so we have a group of neurologists anesthesiologist dentists physical therapists psychologists that specifically tend to orofacial pain problems but if you call no dental work no no I haven't touched a drill in 20 years except to adjust the appliance that's not true that's not correct I do take Medicare in my private practice it will not pay for the appliance for the for the night guard but it sometimes does I mean if you appeal it might but they certainly pay for the appointments because I bill medical code so I build a regular medical visit that's not considered dental because that's the thing that's the insurance wise it's really difficult because they kind of throw the ball at each other the dental insurance says it's a medical issue the medical insurances is a dental issue but it's actually a medical issue it's a joint it's not it's not a dental pathology yes you're welcome


  1. I was diagnose while eating a breadstick, my mom has it, plus I have all the symptoms.

  2. According to ayurveda Incresed Air in body causes TMJ and bending of bones and even psoriasis , and this air causes continuous noise in ears and mental tention.Use oil massage before bath and and also take oil in food .And also use "anu oil" as nasal drops .


  4. is collagen good for a person with TMJ disorders?

  5. can anyone explain the self limiting nature of osteoarthritis? I have it in my left tmj and it's reassuring to hear that it has the potential to heal, but i've read of many people online who have arthritis in their jaw joints and end up getting tmj replacements because of how significant the damage is over time. is it self limiting only in certain scenarios/cases? I've acquired a very minor open bite as a result of the osteoarthritis, but have never once felt any pain associated with it and have had crepitus already for 2-3 years.

  6. at time marker 9 minutes and 24 seconds the speaker said that muscle pain in the masseter or temporalis muscles is a common tmj disorder-REALLY????!!!!

  7. i stopped the video at 4 minutes and 26 seconds because i disagree that popping without pain does not imply a "disorder". if the tmj is "popping" then the articular cartilage disk is not in place when the condylar head is fully seated into the glenoid fossa. it also means the the condylodiskal ligaments have been torn. just because a person can adapt to an injury doesnt mean that they dont have a "disorder". i am going to resume watching now

  8. Hello, is there a way to determine if the lateral ligament or TMJ capsule is torn/detached after trauma?

  9. 23:30 Maybe correct, but I'd like to see what they actually did in those studies. Just because what they did failed doesn't mean there is no correct procedure. It may simply mean what they are doing doesn't work. I'm also not convinced that TMD is a dental problem, but I'm skeptical of vague research claims that don't specify testing or treatment method and extrapolate that to all future testing and treatment.

  10. I saw Dr. Mintz orofacial pain specialist for my TMD and he said to see a psychologist. http://sleep-tmj.com/

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