Medical and Medicare
The temporomandibular joint (TMJ) is a small joint located in front of the ear where the skull and lower jaw meet. It permits the lower (mandible) to move and function.
Temporomandibular disorders (TMD) are not uncommon and have various symptoms. Patients often complain of ear pain, headaches and limited jaw movement. They may also complain of popping, clicking or grating sounds in the joint and feel pain when opening and closing their mouth.
Determining the cause of a TMJ problem is important, because it is the cause that guides the treatment. Common causes of TMJ problems are:
Because there is no known “cure” for TMD, management of patients with TMD symptoms is similar to management of patients with other orthopedic or rheumatologic disorders. The goals of TMD management include decrease in pain, decrease in adverse pressure or “loading” on the jaw joints, restoration of function of the jaw and normal daily activities. These goals are best achieved by identifying all contributing factors and implementing a well defined management program to treat physical, emotional and psychological factors. The management options and sequence of treatment for TMD are consistent with other musculoskeletal disorders found in the body. As in many musculoskeletal conditions, the signs and symptoms of TMD may be temporary and self-limiting without serious long term effects. For these reasons, special effort should be made to avoid aggressive or nonreversible therapy such as surgery, extensive dental treatment or orthodontic treatment. Conservative management techniques such as behavior modification, physical therapy, medication, jaw exercise and orthopedic appliances (orthotics) have proven to be safe and effective in the majority of TMD cases. Most patients suffering from TMD achieve good long term relief with conservative (reversible) therapy. Scientific research demonstrates that over 50% of TMD patients treated with conservative management have few or no ongoing symptoms of TMD.
Type of Treatment
The emerging specialty of Orofacial Pain Dentistry is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of orofacial pain disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches.
The orofacial pain dentist serves as a consultant to other dentists and physicians but is often the principal treating health care provider and may provide care at various levels, such as direct treatment, prescribing medication, prescribing rehabilitative services, performing pain relieving procedures, counseling of patients and families, direction of a multidisciplinary team, coordination of care with other healthcare providers and consultative services to public and private agencies pursuant to optimal healthcare delivery to the patient suffering from a painful disorder.
Patients can expect a thorough evaluation of musculoskeletal and nerve functions of TMJ, head and neck palpations, headache / migraine trigger points, measuring opening/side to side, use of MRI or CT images to accurately diagnose TMD issues, listening to joint sounds for arthritis / crepitus, and evaluation of medication use.
OCCLUSAL ORTHOTIC: It may be recommended that you wear an orthotic (also known as a splint-different from a night guard or bite guard) that fits over either your upper or lower teeth. An orthotic has many different uses and can be worn either full time or part time, depending what your doctor determines is best for you. Generally, orthotics are used to keep the teeth apart, realign the jaw joints and help the jaw muscles relax. The specific design and adjustment of your orthotic will depend upon your condition, how it changes during the time you wear your orthotic, and your overall treatment plan.
TRIGGER POINT INJECTIONS: Many headaches, migraines and facial pain can be pinpointed to a specific trigger point, either a muscle or nerve. By injecting the muscle with medication, the headache and other pain triggers are blocked.
JOINT INJECTIONS: Injections into the TMJ joints, usually includes steroid with anesthetic, to lubricate and relieve pain from joints.
NERVE BLOCKS: Occipital and trigeminal blocks with steroid and anesthetic to diagnose or eliminate pain.
STRESS MANAGEMENT: One treatment approach for your TMD problem is to learn to manage your daily stress. Your doctor may recommend several techniques to help you do this. They may include biofeedback, relaxation breathing, guided imagery, and sometimes referral to a therapist.
PHYSICAL THERAPY: Physical therapists are trained professionals who help rehabilitate all types of physical injuries. There are many different techniques that are helpful and the most common include jaw exercises, postural and ergonomic training, ultrasound, electrical stimulation, and mobilization. Your doctor and physical therapist will work together to formulate a plan for your treatment.
Extensive research is being conducted on the safety and effectiveness of TMD/orofacial pain treatments. Most researchers and clinicians strongly recommend reversible and conservative treatments for TMD. Even when TMD symptoms are long standing and severe, most TMD patients do not require invasive treatment. Treatments designed to permanently change the bite or reposition the jaw with orthodontics or dental reconstruction are not usually necessary and should be undertaken with great care.
If irreversible treatment (permanent change) for TMD or orofacial pain is contemplated, we recommend getting a reliable second opinion.
Specially trained dentists, physical therapists, psychologists and physicians are usually the best source for the proper diagnosis and management of TMD and Orofacial pain.
Headache and Symptoms of Temporomandibular Disorder: An Epidemiological Study
Conclusion- Temporomandibular disorder symptoms are more common in migraine, episodic headache, and chronic daily headache relative to individuals without headache. Magnitude of association is higher for migraine. Future studies should clarify the nature of the relationship.
Method of Injection of Botox of Chronic Migraine is Safe and Effective Treatment
OnabotulinumtoxinA (Botox; Allergan Brand) has now been FDA approved for the treatment of migraine headaches. OnabotulinumtoxinA (Botox) has been reported to relieve pain in a variety of conditions, including migraine headaches. In a recent study in Headache Journal of Head and Face Pain, 89% of patients with episodic migraine who were treated with OnabotulinumtoxinA had complete or partial response of their migraine symptoms, including headache.
Treatment of temporomandibular disorders by stabilizing splints in general dental practice: results after initial treatment
“80% TMD patients were managed effectively by using splints for periods of up to five months.”
“When interested and suitably trained, general dental practitioners can manage four out of five TMD patients with reversible treatment in their own practices.”
Medical treatment of recurrent temporomandibular joint dislocation using botulinum toxin A
Type of Treatment
Pain management encompasses pharmacological, nonpharmacological, and other approaches to prevent, reduce, or stop pain sensations. Pain management can be trial and error. Pain can occur from various sources so a combination of medications may be needed.
Patients will be asked to fill out extensive questionnaires regarding pain levels, and general medical information about how they live with pain. Following the interview and physical exam, they will work with the patient to develop a treatment plan.
Some examples of the different types of medications used for pain management are:
Opiates are frequently used to reduce moderate to severe pain. Medications such as Vicodin, Lortab, and Percocet are often used for acute or breakthrough pain and are generally prescribed for short periods of time. However, if a patient is taking an appropriate amount, the doctor may prescribe for longer periods. Many patients will take these medications long term.
If short acting medication is not adequate enough to decrease the pain, long-acting opiates may be prescribed. These opiates are slowly released into the system over a period of hours or days depending on the medication. Examples are Oxycontin, Duragesic (Fentanyl) patches, MS Contin, and Methadone. It is important to note that these medications can not be stopped abruptly. They need to be slowly tapered off to avoid side effects and withdrawal symptoms. It is essential that dosing instructions are followed carefully to avoid potential problems.
Narcotic Painkillers May Pose Danger to Elderly Patients
Type of Treatment
Many TMJ disorder patients find that a variety of different treatments are necessary to manage chronic jaw pain. This often involves a multi-disciplinary team approach.
Patient's initial exam will focus on the determination of loss of function, palpation of various muscle groups and measuring of jaw opening / side to side. The therapist or doctor will then diagnose and create a treatment plan to regain any loss of function using various modalities.
Treatment modalities may include:
Limited evidence to support the use of physical therapy and chiropractic for temporomandibular disorder
Type of Treatment
A general dentist is usually the primary care dental provider. This dentist diagnoses, treats, and manages overall oral health care needs, including gum care, root canals, fillings, crowns, veneers, bridges, and preventive education.
Patients can expect a thorough and comprehensive oral examination, as well as radiographic exam (with X-Ray). The focus will be on the patientÕs occlusion (bite). The doctor will take jaw measurements, palpate and note jaw sounds. The extent of the exam will be based on the dentistÕs experience and training with treating TMJ.
Since the teeth, jaw joints, and muscles can all be involved, treatment for this condition varies. Typically, treatment will involve several phases. The first goal is to relieve the muscle spasm and pain. Then, your dentist must correct the way the teeth fit together. Often a temporary device (known as an orthotic, or "splint") is worn over the teeth until the bite is stabilized. Permanent correction may involve selective re-shaping of the teeth, building crowns on the teeth, orthodontics, or a permanent appliance to lie over the teeth. If the jaw joint itself is damaged, it must be specifically treated. Though infrequent, surgery is sometimes required to correct a damaged joint. Ultimately, your dentist will stabilize your bite so that the teeth, muscles, and joints all work together without strain. The important aim of correcting your bite is to insure optimal long-term health.
OCCLUSAL CORRECTION: Sometimes it is necessary to improve the way your teeth fit together. This can be accomplished in different ways. Grinding down certain teeth so others can touch is one method.
Bite Reconstruction is accomplished through extensive dental work like crowns, bridges and, if indicated, implants. This is done to replace missing teeth or to change the size and shape of the teeth so they fit and function together in a more harmonious manner with the jaw joints and muscles.
Risk management in clinical practice. Part 3. Crowns and bridges
“Patients should be warned regarding risk of loss of vitality with fixed restorations”
Crowns and extra-coronal restorations: Considerations when planning treatment
“The damage to tooth tissue when providing crowns is considerable and should be weighed against the benefits”
Type of Treatment
An orthodontist is a dental specialist that has completed an additional 2 to 3 years residency program accredited by the ADA of advanced education in orthodontics. After receiving the additional years of training and education, an orthodontist has learned the skills that are required to treat the misalignment of teeth and facial development with braces, retainers, headgear and other methods.
Patients can expect a detailed study and examination of their teeth. During this examination, X-rays of your head, neck, jaws and teeth will be taken. Pictures of your profile, face and teeth will also be used. An evaluation of your mouth will determine what type of bite problem (malocclusion) you may have.
The orthodontist may make impressions of your teeth from which dental models of your teeth will be made. This involves pressing a soft material over your teeth and leaving it for a minute or two to harden. Then plaster is poured in the impressions to make the dental models. You will be asked to bite into a soft piece of wax for a few seconds so that the dental models can be lined up to match your bite.
Orthodontics, usually with braces, can move your teeth so they fit together better. In some cases, if the jaws themselves are misaligned, the jaws are moved with a combination of orthodontics and oral surgery called orthognathic surgery.
The overall findings of orthodontic clinical studies
Currently, and based on the available evidence, the widely accepted conclusion is that orthodontic treatment neither causes nor cures TMD...
Type of Treatment
Oral and Maxillofacial Surgeons care for patients with problem wisdom teeth, facial pain, and misaligned jaws. They treat accident victims suffering facial injuries, place dental implants, care for patients with oral cancer, tumors and cysts of the jaws, and perform facial cosmetic surgery.
Patients will be required to obtain X-Ray or CT images for the initial consultation for the doctor to evaluate and explain diagnosis and discuss treatment options. Occasionally an MRI will be ordered.
Surgery is sometimes done to repair or reconstruct the joints when more conservative treatment has failed to improve comfort and function. While rarely needed, surgery can be performed to eliminate debris that accumulated in the joint, to repair damaged tissues and to even replace entire joints, similar to the replacement of other joints like knees, hips and shoulders.
TMD disorders: A patients' and clinicians' perception of the outcome of temporomandibular joint arthroscopy
Conclusion Overall, 50% of patients seemed to view arthroscopy favorably although many patients still felt that jaw opening was restricted. The outcome was not related to the position and reducibility of the disc at surgery and other variables may be responsible. The disparity between the clinical evaluation and the patients' perception of effectiveness emphasizes the importance of patient feedback.
Clinical evaluation of patients with failed TMJ implants
Oral surgery: Patients referred to a specialist clinic because of suspected temporomandibular disorders: a survey of 3194 patients in respect of diagnoses, treatments, and treatment outcome
“Most patients responded quickly with conservative treatment methods.”
Type of Treatment
To put it simply, the belief of neuromuscular dentistry places the jaw into a relaxed position, relieving the symptoms associated with TMJ. While traditional dentistry evaluates primarily the teeth, bones, and gums, neuromuscular dentistry works with the hard tissues and the soft tissues, muscles and nerves.
People who suffer from these problems are thought to have an imbalance in the jaw-to-skull and spinal relationship, which is caused by a bad bite (malocclusion). Most neuromuscular dentists believe the bad bite can be the cause of many body pains and illnesses.
Your muscles and jaw will be tested with high tech equipment and you will be able to see your current jaw and muscle problems. Some dentists will also do a full spinal and cranial exam.
Neuromuscular Dentistry serves to change the bite and realign the jaw.
First the dentist determines the optimal position of the jaw by measuring the relaxed position of the head and neck muscles, and then repositions the jaw to achieve those exact measurements.
The Treatment usually involves adjusting the bite using orthotics (splints) to the optimal position, and ultimately restoring the teeth to their correct positions by in most cases placing crowns on every tooth. This allows the dentist to control jaw position.
The Belief is that your pain will go away after all this work is completed.
The analysis is $1,500 to $5,000, to determine your problem and usually not covered by insurance. The cost in many cases ranges from $20,000 to $50,000, dental insurance may cover some of this, however most dental insurance only covers up to $1,500-$2,500. Thus is a substantial investment.
The research is mixed, and there is actually a fair amount of research showing the majority of the population has a bad bite and only approximately 10% develop TMJ, TMD problems independent of their bite. Thus there is no correlation between a bad bite and the development of these problems.
Even though there is little to no double blinded, university based research that backs the neuromuscular approach, some people do experience relief.
Malocclusion: a term in need of dropping or redefinition?
“I would argue that an occlusion cannot be considered to be intrinsically bad or wrong. Rather it is the case that there may be an intolerable number of times for a patient to function or parafunction on an occlusion at that particular stage in their life.”
“This philosophy does not sit easily with those dentists who would like to blame occlusion for a whole host of effects and pathologies.”
The term 'phantom bite' is used to describe an uncommon condition in which patients are preoccupied with their dental occlusion, believing that it is abnormal. Phantom bite can be a disabling disorder which is difficult to treat. Available evidence suggests that the symptoms cannot be improved by occlusal treatments. It is therefore essential to avoid extensive irreversible restorative treatment. General dental practitioners should refer patients for specialist opinion and management.
|Types of Treatment||Reversible /Non Invasive Treatment||Average Time of Treatment||Average Cost of Treatment ($)||Medical Insurance Accepted||Dental Insurance Accepted (Max of $2500 avg.)||Medicare|
|Physical Therapy / Chiropractic||
|General Dentistry||2 week-1 year||400-20,000||
|Oral & Maxillofacial Surgery||60 Days||20,000-50,000||
|Neuromuscular Dentistry||1 year||20,000-50,000|
Above information is based off averages and may differ from practice to practice.
The TMJA conducted an on-line survey asking "What do TMJ patients want?" The following is a summary of the top 20 responses we received.