Posted: Jun 9, 2011 7:15 PM
Temporomandibular disorders are a group of problems that cause pain and poor function in the jaw joint and the muscles responsible for jaw movement. They're also called TMD, or TMJ (short for temporomandibular joint) disorders.
TMD can be just a nuisance -- or it can be a life-altering problem. When it's less severe, crunching down on a hard bit of food can shoot a bolt of pain through the jaw joint -- unpleasant, to be sure, but not serious. With time and simple home care, the pain usually subsides.
But with severe TMD, simple tasks, such as eating or talking, can no longer be taken for granted. "It can be incredibly debilitating," says Matthew J. Messina, DDS, a dentist in Cleveland and a spokesman for the American Dental Association.
For some people, the disc within the jaw joint slips out of position during sleep, he says. "All of a sudden, they'll wake up in the morning and they can't open their mouth more than 10 millimeters and a normal opening is 50 millimeters or so. So imagine you're trying to eat breakfast and you can't open your mouth wide enough to get the toast in there. That can be very panicking."
If you believe that you might have TMD, where do you start seeking help?
When symptoms of TMD surface, they might include:
TMD may affect more than 10 million Americans, according to the National Institutes of Health. Women are affected more often than men.
Usually, a dentist is the first health professional to consult, Messina and other experts tell WebMD. In fact, patients who experience popping, clicking, or pain in the jaw joint will often call their dentist first.
To check for TMD, a dentist will ask about symptoms, take a medical and dental history, and examine the head, neck, face, teeth, and jaw.
But some people go to their primary care doctor if they have less obvious TMD symptoms, such as headaches, neck pain, ringing in the ear, or a sense of fullness in the ear that makes them suspect an ear infection, Messina says.
Although oral and maxillofacial surgeons are trained in TMD, most patients don't go to an oral surgeon first unless they have a locking problem with their jaw, Messina says. "Either their jaw is locking open or locking closed. Sometimes, they'll seek a surgeon out first because they've self-diagnosed their problem as being extremely severe," he says.
The large majority of temporomandibular disorders stem from jaw muscle problems that cause pain and tightness. "Luckily, most... are muscle spasm problems," Messina says.
In contrast, only a small minority of cases stem from problems within the jaw joint itself, he says. These include a disk that moves out of proper position, strained ligaments, osteoarthritis, and other joint-related conditions, Messina says.
Fortunately, Messina says, "the vast majority of [TMD] will not require surgical intervention."
Instead, most patients can try nonsurgical treatments, which don't cure TMD, but help to relieve pain and improve function. Experts tell WebMD that it's crucial to try these methods before resorting to surgery or other treatments that result in permanent changes to the jaw or teeth.
Nonsurgical treatments include:
Stabilization or bite splint: This main treatment for jaw muscle pain and tightness involves using a plastic guard that fits over the upper or lower teeth. "It allows the teeth to slide smoothly against each other, which lets the jaw muscles relax," Messina says. Splinting helps to prevent clenching and grinding of the teeth. Most people wear the splint only at night, but in severe cases, Messina says, "the patient may be wearing the splint 24 hours a day, except when they're eating."
Physical therapy: "Physical therapy involves muscle relaxation and increasing the range of motion in the joint," Messina says. These methods may include biofeedback, stretching exercises, or ultrasound treatments. Applying warm compresses to the side of the face during exercises may be useful, too, Messina says.
Yoga, meditation, acupuncture, and stress management can also help ease symptoms, Messina says. "Stress doesn't cause [TMD], but it certainly makes it worse," he says.
Richard Ohrbach, DDS, PhD, is a dentist and a clinical psychologist. Among his treatments for TMD, he teaches some patients relaxation skills to help them cope with pain. "Patients just benefit from learning how to really relax their bodies," says Ohrbach, who is also an associate professor of oral diagnostic sciences at the University at Buffalo.
Drug therapy: These treatments include anti-inflammatory medications to relieve pain and prescription muscle relaxants. "If there are some severely inflamed muscles that have restricted motion because they're in spasm -- the muscles are excessively contracted or hyperactive -- we can use some muscle relaxants," Messina says.
Experts agree that nonsurgical treatments should be tried first -- unless there's a compelling reason for immediate surgery, such as a tumor in the jaw joint.
Temporomandibular joint surgeries carry risks, Messina says. "Post-surgically, some pain in the joint tends to be fairly common." Other surgical complications include nerve damage, bleeding, infection, and scarring of the joint.
In the past, too many people were sent to surgery right away, Ohrbach says. Since those days, he says, "we've learned that displaced discs and clicking joints and even locking joints can largely be managed...through nonsurgical treatments."
Indeed, some research backs up that approach. In one 2007 study published in the Journal of Dental Research, scientists found that patients with jaw locking from a permanently displaced disc fared equally well with nonsurgical versus surgical treatment.
"We took patients with the worst joint condition, where the jaw was locked and they couldn't open [it] and had very severe pain and limitations with eating," says Eric L. Schiffman, DDS, MS, an associate professor and director of the division of TMD and orofacial pain at the University of Minnesota, who led that study.
In the study, 106 patients were randomly assigned to receive "medical management" (which included home-based self-care, short-term medications, splints, physical therapy, and visits with health psychologists to help them with relaxation and oral habits), or to receive medical management plus surgery.
"We found that only 5% of the people in the nonsurgical group ever needed surgery and that the surgical group really didn't do any better than the nonsurgical group over a 5-year period," Schiffman says. "We thought that surgery might make the joint more normal and in the vast majority of cases, it doesn't." Those findings have helped to guide how health professionals currently treat TMD, he says.
However, if a patient has exhausted nonsurgical treatments and still has significant pain, it might be time to bring an oral surgeon into the treatment plan, experts say.
If surgery is being considered, it should be reserved for those with true jaw joint disorders, not jaw muscle disorders, according to Daniel M. Laskin, DDS, MS, a professor in the Virginia Commonwealth University department of oral and maxillofacial surgery and a spokesman for the American Association of Oral and Maxillofacial Surgeons. "The patients who have muscle problems should never have surgery," he says.
Even then, only some patients with a joint disorder need surgery -- not all of them, Laskin says.
Two joint disorders are the most common, Laskin says: internal derangement, in which the disc within the jaw joint slips from its normal position, and degenerative joint disease.
"Even those, you start out trying to treat them nonsurgically," Laskin says. Schiffman agrees and usually recommends at least three months of nonsurgical treatment for disc displacement or degenerative joint disease before considering surgery.
Many experts urge patients to get a second independent opinion before having any surgery on the jaw joint.
If a patient decides on surgery, Schiffman offers this rule of thumb: "Keep it as simple as possible."
That might mean opting for arthroscopic surgery to remove scar tissue and flush out the joint area, or athrocentesis, a procedure in which a needle is inserted into the joint to irrigate it and flush out debris.
"I would say that these are minimally invasive, and typically, the patients are either better or at least they're not worse off," Schiffman says. "Those typically are more than adequate. The more invasive treatments only increase the risk without a demonstrative improvement."
One example of a more invasive surgery involves reshaping the disc or sewing it back into place. "In general, the surgery doesn't seem to be highly successful at keeping the disc in place," Schiffman says. "I want to point out, however, that oftentimes, patients do improve in [symptoms] such as pain. But if you want to try to make a joint normal surgically or nonsurgically -- frankly, there is no way."
Despite drawbacks, Schiffman emphasizes that some patients can benefit from temporomandibular joint surgery, so it shouldn't be ruled out if it's genuinely worth a try. For example, he has seen patients whose jaws lock 20 to 30 times a day, he says. "In those cases, to not do surgery -- or at least not offer it to them as a viable option -- is not appropriate."
Total jaw joint replacement may also be done on people with systemic joint diseases, such as rheumatoid arthritis, or if they have cancer or failed jaw joint surgeries. However, the National Institute of Dental and Craniofacial Research warns that surgery to replace or repair a jaw joint is controversial, irreversible, and should be avoided, if possible.
There's no certified specialty in TMD either in medicine or dentistry, so how does one to find a good dentist or oral surgeon?
Some dentists are more skilled than their peers at treating TMD, Messina says. Ohrbach recommends looking for a dentist who has done residency training in TMD or facial pain problems at a dental school. A university-affiliated dental clinic that treats TMD may be another good source of care, he says.
If needed, ask a good dentist for a referral to an oral and maxillofacial surgeon, Messina says. Be aware that not all of these surgeons do temporomandibular joint surgeries, he adds. Laskin suggests that patients be sure to look for a surgeon who is board-certified.
Universities are also a good place to find an oral surgeon. "Typically, the university centers are the ones that are the most up to date on the latest procedures or are aware of whom they've trained," Schiffman says.