21 Mar A PSA for TMJ
Today I want to talk about a very important subject. Something I know that most people will resonate with in one form or fashion. I hope you read this and feel compelled to pass it along to your friends because I know first hand how many people struggle with this same condition. What’s more is that they don’t know they have it, they don’t know how much trouble it’s causing them, and they don’t know how easy it is to treat. Stay tuned, first a little background on the condition we call “TMJ” or “TMD”.
Temporomandibular Dysfunction or TMD for short, is the same condition as “TMJ”. “TMD” replaced “TMJ” as the vernacular because TMJ stands for Temporomandibular Joint. That’s the joint that attaches your lower jaw to your skull just in front of your ear. Stick your finger in front of your ear and open wide; you’ll feel it right there. The term “TMJ” doesn’t make sense because we’ve all got one. That would be like saying you’ve got “knee” disease or “chin” disease. At any one time 15-20% of America’s population is suffering from symptoms of TMD, however the vast majority of us have suffered from it from time to time. Symptoms vary greatly from mild jaw soreness to debilitating pain that lasts for months. TMD is an umbrella term that means you have dysfunction of any of the four muscles that help you eat or your jaw joints. Symptoms include: headaches in your temple area, neck and shoulder pain, pain in the corner of your jaw, earache, tinnitus, clicking and popping of your jaw joint, difficulty chewing, difficulty opening or closing, sore teeth, and generalized sensitive teeth that don’t get better with the use of sensitivity toothpaste. Symptoms can be vague or specific, sporadic or consistent. Ever had any of those? I thought you might. Here is a picture of what I’m talking about.
So what’s all this mean for you? Well that’s my favorite subject, and why I began treating this condition. My problem was and continues to be that healthcare providers overcomplicate 95% of these conditions. This is because #1 they lack education and experience, and #2 providers have an angle at which they are trying to get compensated to treat this condition. Dentists, chiropractors, massage therapists, acupuncturists, physical therapists et. don’t get paid to have prolonged conversations with people. They get paid to do treatment. What’s more is that they each approach this condition through the eyes of “their” treatment and lack the skill to differentiate remedies based on what is causing the issue and what will fix it. I promise you, nothing frustrates me more. Case in point. Go tell your dentist you’re having headaches. Way too many of them without asking another question will suggest wearing a bite guard. Generally we are talking about a piece of plastic that fits over your teeth which will cost you between 200 and 700 bucks. I promise you these things aren’t blessed by the vatican or fashioned with a magic wand. Why? It’s what we do as dentists. It’s what we’re trained to do. Your dentist is truly trying to help you, not just pay off his new Mercedes. We’re trained to diagnose and fix. Get you out of pain. You got a problem? Boom here’s your solution! Now take a step back. What if they asked you one more question? “When does your headache hurt the most? When you wake up or at 5:00 PM?” “5:00 huh?” That’s the answer I get 75% of the time. Please tell me how sleeping in that night guard is going to help you when your pain is at 5? Let’s take it further. “Have you had any dental work recently that doesn’t feel right? Have you had any accidents lately? Are you going through any stressful times recently?” Now we begin to find out if this is going to be a problem that’s going to hang around if we don’t treat it, or just something in passing that we need to identify.
So what causes pain? In most cases of patients between the ages of 18 and 50 headaches are caused by local muscle soreness of your temporalis muscle. (That one on the side of your head that you clench during your headaches.) You rub it and it feels better. This is the same thing as having a sore muscle from exercising. Again, you rub it, you ice it, and it feels better. It’s caused just the same, by overuse. Only with this, most people have no idea they are causing it. It makes sense that your legs hurt the next day after you ran 3 miles, or that your back hurt the day after cleaning out your attic. But nobody realizes that over the course of a stressful 8 hour day they were clenching their teeth together for half of it. Do this for 3 weeks straight and you’ve got a heck of a workout going. Now the interesting part of this is something I term “pain causing pain.” That’s where your headache actually causes you to clench more because while you’re doing it, it feels somewhat better. Similar to waving your hand back and forth when you burn it. However, when you’re done clenching you’ve actually caused yourself more pain down the road. This is a cycle that gets repeated over and over in board rooms, classrooms, and kitchens all across America until people begin to think they are crazy or have cancer. The fix for this can be very simple. Awareness! Awareness of the position of your teeth. You can’t just simply say “stop clenching”. For two whole weeks you need to ask yourself 30 times a day where your teeth are at. And when you find them touching each other you are activating those temporalis muscles and causing yourself pain. Let your jaw relax, your shoulders down, let your tongue fall, and puff some air out of your relaxed lips. Once you break this pain cycle, and you should, you won’t need to be aware as much anymore. This is because you no longer have “pain causing pain.” At least for now.
Now, you can see how much time it takes to talk about each individual problem with TMD. Local muscle soreness might account for 75% of people’s symptoms but there are a wide array of more specific and potentially more problematic conditions that account for the other 25%, and may require specialty care from a neurologist or Oral Facial Pain specialist. However general dentists can and should treat the vast majority of patients. So this leaves conditions involving your joint. Recently I’ve been doing a lot of work with the Ear Nose and Throat doctors in our town. I’ve been told that up to a third of the patients they seen on a daily basis with “ear aches” actually have TMD. So what’s up with this? Well it goes back to location. Remember sticking your finger in front of your ear? Try again, and open wide. Now you’ve got a really, I mean really complicated joint there. Your lower jaw is suspended in a sling attached to your skull with just a little piece of cartilage between the two. Now put your finger there and take little bites. Don’t feel much do you? Now open wide. See the difference? Your lower jaw translates out of its socket, almost as if it comes unhinged. And when it does everything has to come with it in perfect harmony and right back into place when you close. Think about how many times this has to occur perfectly in your life. Things can wear out. Think about your tires, think about your shoes. They last a couple years. This thing has to open and close hundreds of times a day for 75 years. Now it does a pretty could job, but what happens if we add unnecessary force. There’s two kinds, acute and chronic. Acute is a good swift blow. A car accident or a punch. That could change the shape of something in a hurry, but you would likely know it and your pain would make sense. The other is chronic. This is the trouble one. What if every day and every night for 6 months you put pressure from clenching on that little piece of cartilage. Look at that picture up above. You think it might change shape? You think it might become inflamed? You better believe it. Now you have something that might feel like an earache, or a joint that clicks and pops because the shape of things have changed in there and it no longer can translate or move back and forth freely. This condition you’re going to need a little help with, but it’s usually very treatable, and step 1 is understanding your body. That’s a much longer conversation.
So what do we do? How do we fix this? And what are bite guards good for? Well again, step one is understanding your body and your condition. If your doctor is not explaining this to you. If he is just prescribing you medication or a guard then you need to speak with him or find somebody else. I relate this to a back problem more than something like diabetes. You don’t have “TMD” in the sense that you have come down with this horrible affliction you will be forever stuck with. It’s more like a sore back. Now with a sore back some people need surgery, some people need medications, some people need physical therapy, and some people just need to be reminded that they need to quit picking up heavy boxes. It usually comes and goes when you stress it, most don’t need major interventions. This is a great analogy. Now what happens if you’re causing your pain at nighttime? I can’t tell you to stop clenching at night. I promise you you’ll do it twice as much if you try not to. So to stop this we use bite guards or more specifically stabilization appliances. They are more sophisticated than just normal bite guards in that they actually place your jaw joint into its most naturally stable position when you clench. The place your body can handle it best. It works really well and we love doing it because it goes back to our “fix it” training and I get to be the hero with my cool plastic night guard. People who fit this treatment love their nightguards. They name them, they never forget them because they can’t live without them. But again it’s probably only 25% of the people. So what else? Well most of these patients also have neck and shoulder pain. Yes if you’re stressed from facial pain you’ll guard it with your shoulders. Again “pain brings pain”. This is when I get physical therapists involved. They can do dry needling, and other techniques to relax the neck, shoulder, and facial muscles, and getting us to where we’re going faster. It’s just settling down the whole system. Sometimes I’ll do trigger point injections where I inject your muscle with numbing medicine. Yes, that will relax it. Often it’s enough to break the “pain brings pain” cycle. It also slows down the nerves that started out as little trickles of pain 6 months ago, but have become major highways of transmitting pain on a daily basis. Then you’ve got those type “A” people. The “I’m too busy.” “I know better.” “Give me a pill” “Just fix me people”. These are my botox people. And it’s not many at all. These people we’ve tried everything else and we resort to injecting the muscles that elevate and put pressure on the whole system with botox. A medication that reduces their ability to clench as hard. It works great but there’s a big kicker. You never fixed anything. Botox is expensive and you need to do it about 4 times a year because it wears off. Maybe you make enough in your high paced “type A” job that you don’t mind this route, but we reserve it for situations where nothing else is working. Of course there are exceptions and I am only stereotyping. I have some patients that simply can’t feel better with anything other than botox in conjunction with other therapies.
So that sums up the majority of the people I see on a daily basis. The other people usually have chronic problems. Referred pain, neuropathies, joint dislocations, conditions of the central nervous system, arthritis, bad dental work, and other things that really need to be hashed out over a long conversation. For these patients we try to take pain that is controlling their life, A “10 out of 10”, and find ways to shrink it to a “2 out of 10”. For this I usually need help from my colleagues in medicine and physical therapy. Sounds like a bad back doesn’t it? The worst thing we can do is try and give a “one size fits all” treatment approach. Unfortunately that’s where most of our clinicians are today. The other problem is that we try lots of things at one time. “What are you doing for your condition?” “Well I went to the physical therapist, the chiropractor, my doctor, my massage therapist, and I’m using essential oils and none of its working.” “Whoa, hold your horses lady”. We need to do less to treat this. We need to understand it. We need to stimulate your system less instead of getting it all worked up. I promise you, you’re normal. You have lots of pain. Its treatable, and its needs to be dealt with.
I love this topic because it affects so many people. I began treating it because like many other dentists I was interested in selling a night guard. Now I treat this because I see how many people I can help. Because of this my practice is overflowing with great patients. They and their families see me every six months for their cleanings and we touch base on their TMJ. It’s not just about treatment, and it’s one of the most rewarding things that I’ve done as a dentist. If you’re having trouble feel free to call me. If you’re close to Lexington, Ky make an appointment with the Oral Facial pain center at the University of Kentucky. They have been my inspiration and guidance and are the foremost experts in this field. I’m just one of the guys on the front line.