What Is TMJ?
How Is TMJ Diagnosed?
Causes of TMD
TMJ Technologies
Sleep Disorders
Prevalence Sleep Disorders
Obstructive Sleep Apnea (OSA)
Diagnosis & Treatments
What Is TMJ?
“TMJ” stands for temporomandibular joint, or the jaw joint. In fact, there are really two TMJs, one in front of each ear. The TMJ is the joint formed by the temporal bone of the skull (temporo) with the lower jaw or mandible (mandibular). These joints move each time we chew, talk or swallow. Unlike the shoulder or knee, which are ball-and-socket joints, the TMJ is a sliding joint. The sliding allows for pressure placed on the joint to be distributed throughout the joint and not just in one area. Adding to the joint’s complexity is that between the two bones that make up the TMJ (the temporo and mandibular) is a disc, just like those between the bones on your back. Made primarily of cartilage, in the TMJ the disc acts like a third bone. Because it is attached to a muscle, the disc actually moves with certain movements of the TMJ.
One of the difficulties with diagnosing a TMJ disorder is identifying the exact source of the problem. For example, the nerve to the TMJ is a branch of the trigeminal nerve. An injury to this nerve in the TMJ may be confused with neuralgia because the symptoms appear to be the same. The two bones of the TMJ are held together by a series of ligaments, any of which can be damaged. A damaged TMJ ligament usually results in a dislocation of the disc, the lower jaw, or both. Another possible problem may be from muscles that are connected to the bone. A muscle injury may produce pain in the TMJ or abnormal movement of the lower jaw. Careful diagnostic study and testing is needed to determine the precise source of any TMJ problem.
A TMJ disorder is simply a disruption in the action of the jaw, usually accompanied by pain. There are a number of conditions affecting the function of the jaw that can cause one of these disorders. Fortunately, because the jaw is made up of bone and other living tissue, it is alive, making it capable of repair and healing.
Any malfunction prevents the complex system of muscles, bones and joints working together in harmony. The result is a TMJ disorder – also known as TMD or CMD (cranio-mandibular dysfunction). Generally, a malfunction of one or both of these jaw joints is caused by trauma, whiplash, bad bite (malocclusion), poor posture, teeth grinding or skeletal malformation. It is estimated that one in every four people suffer from TMJ symptoms.
Do you have a TMJ problem?
People with TMJ problems generally experience one or more of the following symptoms:
• Chronic recurring headaches
• Clicking, popping or grating sound in the jaw joints
• Earaches, congestion or ringing ears
• Limited jaw opening or locking
• Dizziness
• Pain when chewing
• Neck and/or throat pain
• Difficulty in closing the teeth together
• Tired, tight jaws
• Pain behind the eyes
• Scalp tenderness
• Swallowing difficulty
• Pain in the tongue, gums or cheek muscles
• Teeth grinding or clenching
How Is TMJ Diagnosed?
Depending on the nature and severity of the problem, the evaluation of hard tissues my be accomplished using x-rays and CT scans. Soft tissue is evaluated using MRIs, Joint Vibration Analysis (JVA) and electromyography (EMG). Jaw movements are documented using the Jaw Tracker (JT). Occlusion is evaluated using the T-Scan. More information about these diagnostic technologies appears on the technology page of this website.
The evaluation process will include:
Detailed Medical and Dental History.
A complete medical history must be documented, including all past medical and/or dental problems and treatments, any history of trauma (especially to the head and neck region), specific questions about your symptoms, and the nature and duration of any pain and jaw problems.
Physical Examination.
A complete physical examination for a TMJ problem will likely include:
1. Postural exam to discover any musculoskeletal problems that either contribute to or are the result of TMJ problems. This includes scoliosis, lower back pain and short leg syndrome, among others.
2. A cranial examination to evaluate the planes of the skull, including the alignment of the jaw joints and mouth to the rest of the body (dental plane of occlusion).
3. Dental examination to evaluate the shape of the dental arches, swallowing patterns, tooth wear or fractures, missing teeth, existing dental restorations or other clues. The dentist will usually make models of the mouth so that the teeth and dental arches can be more closely examined.
4. Neurologic examination to test for nerve or brain damage that may cause TMJ symptoms.
5. TMJ examination to look at the ranges of motion, gait, speed and smoothness of jaw movement. Additionally, the TM joints will be checked for internal joint inflammation, pain and the presence of joint sounds.
6. Joint Vibrational Analysis, a non-invasive technology that records the vibrations made by joint tissues during movement. The patterns and electronic signature of the patient’s joints are compared with known standards for healthy joints, providing objective proof of a TMD.]
Causes of TMD
Statistics indicate that the vast majority of TMJ problems are caused by trauma. By trauma, we mean an injury as obvious as a blow to the jaw with a fist or something as subtle as a whiplash injury from a car accident that causes direct trauma to the head or jaw.
The most common forms of trauma that cause TMD are:
• Whiplash (cervical acceleration/deceleration)
• Air bag deployment
• Opening the jaw too wide
• Bruxism
• Bad bite (malocclusion)
• Orthodontics
• Ligament laxity
• Stress
• Systemic diseases
Whiplash (Cervical Acceleration/Deceleration).
Whiplash injuries often damage the soft tissue in the neck, back and TMJs. Usually these injuries happen when a car is hit in the rear. The violent motion of the head being thrown from a still state backwards and then forwards again often causes the mouth to be forced open. This produces stretching and/or tearing of the ligaments and connective tissues in one or both TMJs, and possibly bleeding and displacement of the disc in the TMJ. Common complaints after a whiplash injury include neck pain, neck stiffness or difficulty in turning the head, headaches (especially where the neck attaches to the head), TMJ pain, limited ability to open the mouth, TMJ noises, face and/or ear pain, change in bite, dizziness, visual changes (such as light sensitivity or blurry vision) and swallowing difficulties or hoarseness.
Air Bag Deployment.
While air bags have undoubtedly saved lives, they have also been implicated in causing TMJ problems. Patients who have been injured with air bags often experience one or more of the following symptoms: burned or abraded skin on the chin, face or nose; almost immediate TMJ pain; swelling of the TMJs; limited mouth opening; neck pain; and change in the dental occlusion (bite).
Opening the Jaw Too Wide.
All joints have limitations to movement, and the TMJ is no exception. If you open wide for a long time or if your mouth is forced wide open, ligaments may be torn, swelling and bruising develop and disc dislocation may occur.
Bruxism.
Bruxism is the abnormal grinding of the teeth. Bruxism usually occurs during sleep, which is why many people don’t realize they are doing it. But when grinding continues, TMJ problems may develop. An indication that a person is grinding their teeth in their sleep is sore jaw muscles when waking. Minimally, bruxism may produce muscle pain, tooth sensitivity or worn teeth. In some cases, the pressure to the TMJ from constant grinding of teeth leads to ligament injuries, which might cause the disc to dislocate.
Bad Bite (Malocclusion).
A bad bite, or malocclusion, may be produced by poor development of the jaws, removal of teeth without replacement, a high dental restoration, a poor fitting denture or partial denture, or a displaced TMJ disc.
Orthodontics.
Some dentists feel that orthodontic treatment, or braces, might be a cause of TMJ. By moving teeth with orthodontic appliances, malocclusion is produced during treatment. That’s probably why many people undergoing orthodontics report sensitive teeth, pain in the jaw muscles or even bruxism. However, there is no scientific proof that orthodontic treatment produces TMJ problems, particularly once the treatment has been completed.
Ligament Laxity.
People who appear to be double-jointed suffer from a problem termed aligament laxity. When this occurs, a joint appears to be double – or loose. This does happen to the TMJ. Ligament laxity is a fairly common problem in active young women who suffer with TMJ problems and, often, injuries to other joints.
Stress.
Stress has many effects on our bodies: some good and some bad. Physiological changes can produce muscle tightness and pain. When a person is subjected to chronic stress, these physical changes may produce harmful effects. When it comes to TMJ problems, stress is like throwing gasoline on a fire. The gasoline doesn’t produce the fire, but it does make it worse. Similarly stress intensifies TMJ problems. Muscles tighten, teeth clench, abnormal pressure is forced against the TMJ disc, and if the ligaments are weak or if the patient is one that has ligament laxity, the disc may dislocate.
Systemic Diseases.
Various diseases can cause or aggravate TMJ problems. Immune disorders, such as rheumatoid arthritis, psoriatic arthritis and systemic lupus erythematosus, can produce inflammation in the TMJ. Additionally, viral infections, such as mononucleosis, mumps and measles, can cause damage to the surfaces of the TMJ, which can lead to an internal derangement.
There are a number of other pain disorders that are often confused with TMJ because they involve pain in the jaw. Most common among these are:
• Temporal Tendinitis
• Ernest Syndrome
• Occipital Neuralgia
• Trigeminal Neuralgia
• Atypical Trigeminal Neuralgia
• Atypical Face Pain
• Neuralgia Inducing Cavitational Osteonecrosis (NICO)
Temporal Tendinitis – The “Migraine Mimic”.
Temporal tendinitis has been called “the migraine mimic” because so many of its symptoms are similar to migraine headache pain. It is characterized by TMJ pain, ear pain and pressure, temporal headaches, cheek pain, tooth sensitivity and neck and shoulder pain. Treatment consists of injecting local anesthetics and other medications, a soft diet, applying moist heat, using muscle relaxants and anti-inflammatory medications, and physiotherapy. In very rare cases (less than 4%), surgery may be needed.
Ernest Syndrome.
This TMJ-like problem involves a tiny ligament structure that connects the base of the skull with the mandibular or lower jaw. If injured, the structure can produce pain in the face, head, neck, temple, ear, cheek eye, throat and/or TMJ. Treatment of Ernest Syndrome, which is successful about 80% of the time, consists of injections of local anesthetic and medication (like cortisone or Sarapin), physiotherapy and, at times, the use of an intraoral splint.
Occipital Neuralgia.
This disorder is characterized by pain radiating to one or both sides of the head, temples, cheek and forehead and particularly pain above and behind the eye.
Trigeminal Neuralgia.
Also known as tic douloureux, this is a disorder of the trigeminal, or fifth cranial nerve. It is characterized by sharp electrical pain, which lasts for seconds. The pain is triggered by touching a specific area of the skin, as when washing, shaving, applying makeup, brushing the teeth, kissing or even from exposure to cold air. The pain is often very severe.
Atypical Trigeminal Neuralgia.
In contrast to the typical type, atypical trigeminal neuralgia produces constant pain that increases or decreases in intensity. There are trigger zones, but there is also an area of dull aching. A common cause of this disorder is trauma, especially after a surgical incision or blow to the face. (June: how is it treated? does it go away or is it chronic? what do you do for it?)
Atypical Face Pain.
While the same trigeminal nerve is involved in atypical face pain, in this case the facial pain seems to affect people who are under a tremendous amount of stress or have a history of psychiatric problems.
Neuralgia Inducing Cavitational Osteonecrosis (NICO).
Also known as osteocavitational lesions or Ratner’s bone cavities, this disorder produces pain similar to that of typical and atypical trigeminal neuralgia as well as referred pain patterns. There are trigger areas for the pain, which, in this case, develop directly over areas of dead bone. Generally, the lower jaw is affected more often than the upper jaw.
TMJ Technologies
At the TMJ & Sleep Therapy Centre, we pride ourselves on using the most current, proven and accepted non-invasive diagnostic equipment available to help identify your particular situation and treatment needs. This encompasses leading technologies used to diagnose TMJ problems and monitor treatment progress, including:
• Joint Vibration Analysis (JVA)
• Jaw Tracking (JT)
• Electromyography (EMG)
• BioTENS and BioPAK Bite Registration
• T-Scan II
• Radiographs
Joint Vibration Analysis (JVA).
This equipment (approved by the ADA) measures how well the TMJ functions while in motion. This is accomplished by placing headphones over the joints and recording the vibrations of either soft tissue or bone-on-bone grinding. Dr. Olmos feels this device is mandatory when determining what position the mandible (lower jaw bone) should be placed in therapy. This technology also serves as objective proof of what is happening to the joint as it functions and is dramatically less expensive and time consuming than an MRI.
Jaw Tracking (JT).
Also known as electrognathography, this equipment offers the ability to track jaw movements three-dimensionally and record the point of dysfunction, all non-invasively. A headset is placed on the patient. A specialized magnet is placed inside the patient’s lower front teeth. Then a recording of the lower jaw movement is made. This information is vital for identifying the correction needed.
Electromyography (EMG).
This equipment evaluates muscle tension through sensors that are placed over the patient’s head. The information it produces tells the practitioner if the problem is ascending up the spinal cord from below the neck or if it is descending. This information is very important in correcting posture problems that are either the origin or the effect of the TMD. Swallowing, chewing, clenching and bite problems can also be effectively identified using EMG.
BioTENS and BioPAK Bite Registration.
This portable equipment helps reduce facial pain for many patients. BioTENS is a compact, ultra-low frequency, electrical neural stimulator that delivers a precisely regulated, rhythmic stimulus to both masticatory and facial muscles. A single pair of electrodes mildly stimulate cranial nerves that affect key muscles in the face, jaw and parts of the neck. This relaxes the muscles, thereby reducing facial pain. BioPAK Bite Registration provides key data on the patient’s different bite relationships which helps the doctor to better understand the dysfunction that may be causing or contributing to TMD.
T-Scan II.
This technology is used to precisely document a patient’s bite (occlusion). A sensor is placed in the patient’s mouth using a special handle. As the patient bites on the ultra thin sensor, the T-Scan II software scans the movement and displays the occlusion on a computer screen. The timing and force of the tooth contacts are shown in color-coded contour images. This information allows for instant diagnosis of occlusion problems.
Radiographs.
This imaging technology provides x-rays of the head and neck as well as complex motions and elliptical slices of the head. These images are much more comprehensive than typical dental and cranial x-rays and are useful in determining the precise source of a TMJ problem.
Sleep Disorders
Prevalence of Sleep Disorders
It is estimated that one-third of the U.S. population suffers from sleep disorders. Approximately 40 million individuals are chronic sufferers, yet less than 10% have been diagnosed or sought treatment.
Regardless of the type of sleep disorder, the impact on individuals is considerable. Clinically, people suffering from sleep disorders have an increased likelihood of cardiovascular disease, hypertension and mortality. At the same time, these individuals experience reduced cognitive performance that lowers job performance, decreases their quality of life and makes them ten times more likely to be in an automobile accident. These individuals are more susceptible to work-related injuries, depression and family discord, too.
Economically, sleep disorders in the U.S. are estimated to cost $60 - $115 billion annually for medical and indirect expenses. Sleep studies and therapies alone cost an estimated $5 billion per year. Individuals with undiagnosed sleep disorders have also been documented as heavy users of medical services.
Seven types of sleep disorders occur most frequently in the U.S. We have many treatments that can improve the symptoms of those disorders but they may be permanent problems. The disorders that you are looking at are conditions where a nerve may have an irreversible injury peripherally or in the CNS (brain) or the last one in the bone. We use low level or cold laser treatments in combination with medications and our appliance therapy to reduce symptoms and improve quality of life. The combination of treatment in this way usually reduces or sometimes eliminates the dosage of medications and therefore the side effects (drowsiness, fatigue, constipation, dizziness, etc), which in itself improves quality of life.:
• Sleep Apnea Syndrome, affecting an estimated 20 million individuals
• Chronic/Severe Insomnia, affecting an estimated 20 million individuals
• Circadian Rhythm Disorder, affecting an estimated 17 million individuals
• RLS/PLMD: Restless Leg Syndrome / Periodic Limb Movement Disorder, affecting an estimated 10 million individuals
• Parasomnia, affecting an estimated 3 million individuals
• Cheyne-Stokes, affecting an estimated 1.5 million individuals
• Narcolepsy, affecting an estimated 300,000 individuals
Obstructive Sleep Apnea (OSA)
Sleep apnea, known as obstructive sleep apnea (OSA), is more common in the U.S. than asthma or diabetes. Generally, the disorder strikes men more often than women and it progressively worsens with age and increased weight. Basically, during sleep, relaxed muscle activity leads to a closing of the throat and airway, which forces sufferers to take in a deep breath of air and awakens them. This cycle repeats throughout the night, preventing the individual from getting a restful, deep sleep.
Clinical signs and symptoms of OSA include:
• Intermittent snoring with pauses
• Awakenings with gasping or choking
• Gastro-esophageal reflux (GERD)
• Fragmented, non-refreshing, light sleep
• Excessive daytime sleepiness
• Poor memory and/or clouded intellect
• Irritability
• Morning headaches
• Decreased sex drive or impotence
Leading risk factors for OSA are obesity, increasing age, male gender, anatomic abnormalities of the upper airway, a family history of sleep apnea, alcohol or sedative use, smoking and hypertension.
What exactly happens to cause sleep apnea? The image below demonstrates the debilitating cycle of OSA.
Diagnosis & Treatments
The best way to diagnose OSA (or any sleep disorder) is to catch them when they are happening. That is why there are essentially two alternatives for diagnosing them: in a sleep lab or at home.
At the TMJ & Sleep Therapy Centre we use the latest diagnostic equipment for sleep disorders. One of these is the Watch-Pat device which fits comfortably over the patient’s hand and is worn for one night. The resulting data reveals key information, including the number and length of periods that the patient’s sleep was interrupted. We then use this data, combined with other diagnostic tools, to determine the appropriate treatment plan to correct the problem.
Treatment options for OSA fall into three major categories:
1. Lifestyle Changes. Many individuals can relieve the symptoms of OSA by increasing exercise and losing weight. Among other improvements, this reduces fat and increases muscle tone in the throat, which lessens any airway constriction. Lifestyle changes are recommended even in cases when they, alone, will not resolve the problem.
2. Medical Interventions. Many OSA sufferers experience improvements using an at-home sleep device that delivers Continuous Positive Airway Pressure (CPAP). The patient wears a mask to sleep that is attached to a hose and a pump, which supplies air at a stable pressure level to prevent the airway closure that leads to apnea. While effective, the machine can be noisy and cumbersome. In fact, 80% of patients are non-compliant after one year.
In the most severe cases, the only other medical intervention is surgery. This is an option of last resort. During the surgery, portions of the uvula and wall of the throat are removed and the jaw bone may be cut to create a wider airway passage.
3. Dental Orthotic. At the TMJ and Sleep Therapy Centres, we prefer to use non-invasive, customized and affordable dental orthodic appliances whenever possible to reposition the jaw, mouth and teeth in a way that helps prevent airway closure. In 2006, the Academy of Dental Sleep Medicine supported the use of orall appliances as first line treatment option for patients with mild to moderate obstructive sleep apnea and snoring. Dr. Steven Olmos, founder of the TMJ & Sleep Therapy Centres, has created a series of specialized orthotics just for this purpose. We also train and certify other dental professionals and laboratories in the fabrication of such orthotic appliances. These portable devices are placed into the patient’s mouth and worn throughout the night. They are easy to clean and maintain and are noiseless. As a result, many patients prefer the dental orthodics over CPAP.
www.sleepfoundation.org - Teen Signs
www.sleepfoundation.org - Teen Tips
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TMJ Scale
www.tmjscale.com
