Restoration of the occlusal surfaces of the teeth
If the occlusal surfaces of the teeth or the supporting structures have been altered due to inappropriate dental treatment, periodontal disease, or trauma, the proper occlusion may need to be restored. Patients with bridges, crowns, or onlays should be checked for bite discrepancies. These discrepancies, if present, may cause a person to make contact with posterior teeth during sideways chewing motions. These inappropriate contacts are called interferences, and if present, they can cause a patient to subconsciously avoid those motions, as they will provoke a painful response. The result can be excessive strain or even spasms of the chewing muscles. Treatment could include adjusting the restorations or replacing them. (Christensen 1997, A Consumer’s Guide to Dentistry).
Occlusal splints (also called night guards or mouth guards) reduce nighttime clenching in some patients, while increasing clenching activity in other patients. Thus, while occlusal splints do prevent loss of tooth enamel from grinding, use of a splint can
worsen TMJ disorder symptoms for some people.
Nighttime EMG biofeedback (for instance by using a biofeedback headband or biofeedback device) can be used to reduce bruxism and thus reduce or eliminate the ongoing nightly cycle of damage that contributes to the majority of TMJ disorder symptoms. This treatment is non-invasive. The Bruxism Association warns that such devices can disrupt sleep and it does not consider them to be a safe treatment.
While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neurologic in nature, which often does not respond well to these drugs.
An alternative approach is for pain modification, for which off-label use of low-doses of Tricyclic antidepressant that have anti-muscarinic properties (e.g. Amitriptyline or the less sedative Nortriptyline) generally prove more effective. In TMJD the muscles are unbalanced. Biofeedback using EMG is successful in balancing these muscles. A mirror can be used as a biofeedback device: Draw a vertical line on mirror. Relax the jaw by relaxing as you exhale. See the jaw relax in the midline. Practice the breathing and relaxing daily using the mirror. When the jaw does open midline the symptoms should abate.
It is suggested that before the attending dentist commences any plan or approach using medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.
Patients may employ a nighttime biofeedback instrument such as a biofeedback headband or biofeedback device to help them modify para-functional jaw habits which take place in sleep. In addition, there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:
- Manual adjustment of the bite by grinding the teeth (occlusal adjustment). This, too, is not a widely accepted practice and should be avoided as it is irreversible.
- Nighttime biofeedback for para-functional habit modification
- Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
- Reconstructive dentistry
- Arthrocentesis (joint irrigation)
- Surgical repositioning of jaws to correct congenital jaw malformations such as prognathismÂ and retrognathia
- Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)
Elimination of para-functional habits
An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and result in jaw pain. Palpation of these muscles will cause a painful response.
Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A biofeedback headband or biofeedback device may be worn at night to help patients train themselves out of the
para-functional habit of nighttime clenching and grinding (bruxism). A flat-plane full-coverage oral appliance, e.g. a non-repositioning stabilization splint, reduces bruxism in some patients, and can take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the
front teeth only, may prove helpful to some patients, but for those patients who bite harder on this type of splint, even more damage may occur. Thus, different types of splint therapy may work for different patients.
In line with the recommendations of the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), treatments for TMJD should not permanently alter the jaw or teeth, but need to be reversible. To avoid permanent change, over-the-counter or prescription pain medications may be prescribed. Some sufferers may also benefit from gentle stretching or relaxation exercises for the jaw, which may be recommended by their healthcare providers.
Other interventions include:
- Stabilization splint (biteplate, nightguard) is a common but unproven treatment for TMJD. A splint should be properly fitted to avoid exacerbating the problem and used for brief periods of time. The use of the splint should be discontinued if it is painful or increases existing pain.
- FeldenkraisÂ TMJ Program claims to retrain muscles to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJD symptoms.
- Mandibular Repositioning (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. According to an article on Quackwatch.org, MORA devices are considered the most widely used option although their scientific validity has not been proven.
Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have failed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery as a last resort. Other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining professional.
One option for oral surgery is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis. In some cases, this will reduce the inflammatory process.
The jaw can dislocate if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge.
The jaw can also “slide out” as the person is sleeping on their side.