TMJ/TMD Report - TemporoMandibular Dysfunction

• Does your jaw ache?
• Do you get headaches?
• Does your jaw pop?
• Any ringing ears or other ear problems?
• Sore or tense neck muscles?

If so, you may have TMD or Temporomandibular Disorder.

This disorder of the jaw joint (TMJ) can occur when the joint is stressed or damaged from injury, teeth grinding, or from tense unbalanced muscles because of a “bad bite”. The jaw joint can become damaged if your teeth are worn down or missing, or if your chewing motion is unnatural.

When jaw or neck muscles become tense and tired and sore, they become hypertonic with lactic acid build up. Abnormal jaw posture and head/neck posture can make this problem worse.

Here's a partial list of symptoms liked to TMD:

• Headaches - migraine & tension
• Facial pain
• Ringing in the ears
• Ear congestion
• Pain behind the eyes
• Jaw joint noises (popping & clicking)
• Inability to open mouth completely
• Visual disturbances
• Neck and back pain/problems
• Clenching/Grinding teeth
• Uneven tooth wear
• Gum line tooth notching
• Forward head posture

It is not uncommon that people with these problems have already seen many doctors and have tried many remedies in an attempt to find relief. If you have a problem with your jaw joint or dental bite, or experience any of these symptoms, your road to relief begins with determining the extent and source of your problem. A dentist specially trained in the science of managing problems of the jaw joint can offer invaluable help.

This special report will give you some valuable information on this troubling, painful, and potentially disabling problem called temporomandibular dysfunction (TMD), sometimes referred to as “TMJ” (for temporomandibular joint). As always, in order to properly diagnose and treat your specific problem, you must consult with a dentist who is experienced and properly trained in treating headaches and jaw problems.

Towards a better understanding of TMD:

The temporomandibular joint is located in front of the ear and is the place where the lower jaw (mandible) connects with the skull (temporal bone). You can easily located this on yourself and feel the joint in motion by placing your finger on your skin directly in front of your ear - then moving your jaw. As you open and close your mouth, you will feel the joint move forward and backward.

The TM Joint is one of the most unique and complicated joints in the entire body. The lower jaw bone is the only freely functioning bone in the body that crosses the midline. This is important because problems on one side can directly affect the function and health of the joint on the other side. Whether chewing, swallowing, or talking, the joint is constantly working. And for some, it is even working at night during sleep.

Because it is close to the ear, joint problems and muscle spasms are often felt as discomfort in the ear. Ear problems such as ear congestion, pain and ringing in the ears are common complaints with people who have jaw problems or headaches. Frequently people will say that they can’t clear their ears, or that it feels like their ear is full of fluid, or that their hearing sounds muffled. This is due to a spasm in two tiny accessory chewing muscles named the tensor veli palatini and tensor tympani.

Because of excessive muscle tension and stresses placed on the jaw joint, pain can radiate to other areas nearby causing tension headaches, neck, back, or shoulder tightness and pain, eye pain or visual disturbances, teeth and sinus aches, etc.

Migraine headaches are a common finding with people who have jaw problems and neck pain. This is now thought to be the result of high activity levels in the Trigeminal nerve, the major cranial nerve which innervates the head and neck and jaws. When there are high levels of pain and proprioception nerve impulses overloading the nervous system due to chronic tension and pain, vascular headaches like migraines are considerably more likely to occur. Proper balancing of the bite and wise correction of posture will allow this nerve system traffic to lower and reduce the occurrence and severity of head and facial pain and associated problems.

Proper treatment of TMD and headaches requires understanding the dynamic inter-workings of the triad consisting of the jaw joint, the teeth and the muscles. We must work together toward balancing the bite so that the muscles remain relaxed and in balance, and to minimize stress on the jaw joint itself. To better understand these three components, let’s discuss each in turn.

Function of the Jaw Joint

The lower jaw or mandible is “U” shaped bone which crosses the mid-line in front, holds the lower teeth, and turns upward at the angle of the jaw, extending up toward the ear. This top end next to the front of the ear where the lower jaw hinges, is called the condyle. It articulates with the skull in a small depression (the glenoid fossa) on the underside of the temporal bone. Hence the joint is called the temporo-mandibular joint.

When the mouth opens the condyle moves or slides forward as it rotates in the joint or fossa. You can feel this motion by placing the tip of your little finger inside your ear, with pad side pressing forward, and opening your mouth. You will feel the movement of the joint moving away from your finger as the mouth opens and the condyle slides forward away from the ear.

The jaw joint is held together by an assortment of ligaments which form a capsule or space filled with lubricating joint fluid. In the middle of this joint capsule is a protective disc which acts as a shock absorber and prevents the bones from directly grinding on each other. This disc normally sits atop the condyle. Together they move forward during opening which keeps the two bones from rubbing on each other during function.

When there is chronic stresses placed on the joint due to bad bite or jaw posture, the ligaments that secure the disc can become damaged. Often the jaw begins to make noise – you will hear and feel an audible pop or click as you open and close your mouth, sometimes accompanied by pain. Noises in the jaw occur when these ligaments are stretched, and the disc becomes displaced toward the front of the joint. The pop or click noise occurs as the condyle “pops” or moves back onto the displaced disc.

We grade these pops or displaced discs, as being either early, middle or late depending on which part of the open/close cycle the popping event occurs. Generally, the later the click or the more open the mouth when the pop occurs, the worse the prognosis. Some people may indicate that their jaws used to pop in the past, but not any more. We worry for these because this can mean the ligaments are irreparably stretched or torn. Even though there may be an absence of pain or other symptoms, we still insist on treatment because the same basic parameters which started the problem are still present and operational and can continue to do damage to the joint, teeth and muscles.

The Role of Teeth in TMJ Problems

Obviously, we couldn’t complete a discussion about jaw problems without recognizing the role that our teeth play. Of the three components mentioned above, the teeth are the visible partners. You can easily examine teeth and see problems with alignment and cross bites, crowding, spacing, ground off cusps and flattened areas, notching at the gum line, etc.

Often “teeth” problems are inherited or genetic in nature. We tell affected people that they didn’t pick their parents very well – which serves to tongue-in-cheek underscore that these are often complex and difficult cases to figure out. Environment, strength of enamel, diet, presence of fluoride in teeth, access to dental care – all serve as factors that will determine our dental fortunes – (or how many fortunes we may spend in keeping them healthy). Likewise, your inherited genetic adaptive capacities determine how well you can tolerate abuses and stresses to your joints and muscles before they begin to suffer damage or develop symptoms.

Anatomically, the position of the teeth dictate the position of your two jaw bones as they relate to each other. Said another way, your teeth position your “home biting position” which determines the lower jaw’s posture as it relates to the base of the skull. This is important because the lower jaw hangs in a “sling”, suspended below the skull in a sling of muscles and ligaments holding the two parts together. When muscles contract, the lower jaw moves upward to chew or press against the teeth of the upper jaw. This happens several hundreds or even thousands of times each day as we swallow, bite, chew, brace, and otherwise function.

Because teeth are the visible partners in these discussions, it is often easy to see the damage done to the teeth as our teeth grind together. Some people don’t realize that the reason for this wear and tear is due to the hyperactive muscles that power the jaw, and not with the teeth themselves - which brings us to the all important muscles.

The Role of Muscles and Muscle Fatigue

Perhaps you may remember some strenuous exercise or hard work in the garden or yard and waking up with sore muscles the next day. You can also witness the quick pain that comes from holding your arm out straight for several minutes, or ‘sitting on a wall’ with your knees bent. Whether done quickly or slowly, the burn or hurt comes from metabolic activity and waste products built up from stress in the muscle. This happens when the muscle shifts from aerobic (oxygen) to high demand anaerobic (without oxygen) metabolism, which produces lactic acid in the muscle.

When lactic acid and other muscle metabolites build up in muscles, soreness results. It usually takes a day or two of rest to re-fresh the muscle and wash-out these harmful by-products. Long-term sustained chronic muscle tension can lead to damage to the muscles and the establishment of ‘trigger points’ which can be the sources of pain both local and referred to other areas in the region. Even when at “rest”, muscles have at least a minimum level of tonus or electrical muscle activity. Imagine what could happen to a muscle if it remained in constant chronic hyperactivity or stress. This can occur at will (exercise) or involuntarily with regards to maintaining posture.

Another important principle with muscle health has to do “with avoidance conditioning.” Really it is more of a neurological problem. Our nervous system doesn’t like pain or noxious stimuli, and works to do whatever is necessary to avoid or protect us from further noxious, painful or nociceptive sensory input. If you’ve ever had a foot blister or walked with a pebble or sticker in your shoe for awhile, you may have experienced this principle of avoidance conditioning. Work is shifted to other muscles as you try to avoid the hurtful stimulus during function. In this example, your muscles are trying to compensate and adapt for something not being “in balance.”

These basic rules and principles of muscle physiology and posture apply throughout the body. The difference is that the shorter skeletal muscles of the jaws, neck and shoulders, can go much longer and sustain more damage, before the ill effects begin to add up or be noticed. All muscles require rest in order to recover and regain their energy and ability to function in a healthy manner. They need periods of physiologic rest (low electrical firing activity – resting muscle tonus) in order to wash out lactic acid and regenerate. The jaw and neck muscles are no exception, but are often denied the opportunity because of unbalanced postures, forward head positions, and bad dental alignments – all of these being triggers that cause muscle spasms in the jaw and neck muscles.

Postural Adaptations:

Problems of posture are probably the biggest threat to the health of our jaw and neck muscles. If you think of your body as a mass with a center of gravity line extending from the floor up through the top of your head, you can understand that if any weight were shifted away from the center of gravity line, that the mass (your body) would have to fall in that direction due to the forces of gravity, unless muscles were used to act upon the body’s skeletal frame to resist this off-centered force. Muscles attached and anchored to your skeletal frame, brace and hold your body’s weight so that you remain upright and functional. And herein is the rub.

Imagine what happens when you move your head forward into a forward head posture. This 13 pound ‘ball on a stick’, now positioned forward, must be held up by the muscles of the neck and shoulders – or the head will fall forward with eyes looking downward. Due to the natural arighting reflex to lift your head so eyes are even with the horizon, your neck muscles will become tense and fatigued from trying to maintain “proper” upright head position. And because of principles of leverage, for every inch forward your head is postured, gravity adds roughly the weight of the head to what the neck and back muscles must hold up and sustain.

Many people comment that they ‘carry’ stress in their shoulders/necks. What they are really trying to say is that their neck and shoulder muscles are tired from holding a forward head posture. Muscles become fatigued and spent working overtime to hold the weight of the head and then some. You will also notice that he head posture is naturally married or coupled with shoulder position. Where the head goes the shoulder goes, and vice-versa. The key to good head posture is in pulling the shoulders back so that the ears, shoulders, hips and ankles all form a straight line from the floor up.

As an aside, but still part of this posture puzzle, ascending or upward postural problems of the legs, hips, spine, and shoulders, can and do affect the position of the head as it sits balanced on top of this postural chain. Problems below can translate upward to problems in neck and shoulders and jaws as the body tries to adapt or compensate by using muscles to keep the skeletal frame with the weight it is carrying, upright and functional in this world of unrelenting gravity.

Also coupled together in the interconnected world of posture, is the postural position of the mandible and the neck. Neck or cervical posture dictates mandibular posture, and conversely mandibular jaw posture affects neck posture. Problems in one are translated to the other and vice versa. This is where the dental bite plays such an important role because the status of the dental bite dictates the position of the lower jaw as it relates to the cranial base. It also helps explain why in many cases, physicians, chiropractors, physical and massage therapists and other health professionals are unsuccessful in resolving headaches and other postural and neurological problems - because only a properly trained neuromuscular dentist can properly restore the mandible to its proper and relaxed relationship to the base of the skull. This happens through proper diagnosis and properly repositioning the mandible with a repositioning appliance, to a position where the muscles of the jaw and neck can assume a physiologically relaxed muscle state, and the jaw joint can be decompressed and adequately protected.

The same principles of muscle physiology and function that plague the rest of the body apply to the muscles of the head and neck. For example: What happens if the muscles that control the jaw and neck are not ‘happy’ with the unbalanced positioning of the jaw as dictated by the teeth or dental bite? What happens to the muscles of the back, neck and shoulders if the head is positioned forward and the jaw muscles are always clenching or grinding the teeth? If the muscles of the head and neck are tense and fatigued and build up lactic acid by-products from being overworked, the stage is set for the myriad of problems we see in people with TMD. Furthermore, when the joint itself becomes affected or damaged, it can become a primary source of pain which can also cause a reflex heightening of muscles problems.

As we’ve said, muscle tension and pain is a common occurrence with TMD. That is why it is important to deal with, or at least rule out problems of posture if they exist. Successfully managing TMD often involves a multi-disciplinary approach using physical therapists, massage therapists, and/or chiropractors to help with the ‘physical modalities’ of our biomechanical and neuromuscular systems. It is essential to understand that muscle problems can result when the joint is injured, or if the bite is not balanced, or if there are posture problems with the head, neck, or jaws.

In summary, poor posture always results in shifts away from a relaxed and balanced position. This necessitates the use of muscle action to adaptively compensate. This principle applies directly to the jaws through an imbalance in the jaw position or bite due to poor dental alignment, improper skeletal growth patterns, injury or other problems of growth and development.

Forward head posture and mouth breathing resulting from airway problems can cause the head and shoulders to shift forward. When the center of gravity shifts, muscles will be called upon to hold and balance our bodies and keep it functional. Sustained or uncorrected, this increased muscle tension can cause muscles to go into spasm which produces pain, local and referred.

So what are the symptoms again of TMD?

TMJ problems or TM Disorder, refers to a variety of problems associated with a misaligned bite, and jaw and neck posture. Facial pain, shoulder and neck tension and pain, as well as migraine and ‘garden-variety’ tension headaches, are among the more common symptoms.

The list of symptoms and signs linked with TMJ problems is long and complex. This is because of the complex intertwining of the nervous system, muscles, posture, bite arrangement, and function.

The signs and symptoms of TMD include:

• Ringing in the ears (Tinnitis)
• Ear pain, ear congestion
• Dizziness (Vertigo)
• Numbness and pressure in the ear
• Jaw clicking and popping
• Pain behind the eye, and sinus pain
• Facial pain
• Neck and shoulder pain
• Headaches - migraine and tension
• Teeth pain or sensitivity
• Periodontal bone loss (made worse)
• Broken and worn down teeth
• Gum recession
• Insomnia/Depression

Self Analysis:

If you were to examine your own posture here are some principles and keys to look for:

• Look in the mirror standing normally and without posing. Are your shoulders level and parallel with the hips? Are they level or parallel and with the floor? Do you see your shoulders level and parallel with the hips? Is the head tilted or leaning toward one shoulder?
• When viewed from the side, does your ear, shoulder, hip and ankle make a straight line? Is there a normal “S” curve with the shoulders neither forward nor rearward with the head straight up and not leaning front or back?
• When standing upright and natural, are your feet parallel to each other and pointing forward, or is one or both pointed or angled outward? When standing, is there room between the floor and your bare foot for someone to place a finger under the arch of your foot? If not perhaps you have a ‘fallen arch’ or flat foot. This will cause one leg to be shorter to the floor which causes the pelvis to be tipped, and sends compensating postural issues upward as the body tries to stay balanced. You will not likely walk around like a Leaning Tower but will try to compensate upwards by arighting yourself and pulling higher body parts back to center or a more upright position.

Dental posture can be quickly evaluated when looking at your jaw position and your teeth.

• Do you have an overbite? Does your upper teeth cover much or most of your lower teeth when biting together?
• Do you have a cross-bite? Your upper teeth should be outside of your lower teeth. If not, there is a cross-bite.
• Do you have crooked or malaligned teeth?
• Do you have an open bite where you can stick your tongue between your teeth when closed together?
• Do you have ‘abfractions?’ Are there notches in the side of the teeth at the gum line?
• Are your teeth worn down from grinding?
• Do you have missing or shifting teeth? Are there spaces between your teeth?
• Does your jaw feel tired or exhausted often? Does your forehead or temple area feel tight, full of tension or painful?
• Do the muscles in your jaws, over the temple area, and under the jaw feel tired or sore?
• Is there a pop or click in the jaw joint during opening or closing movements?

In Summary - Posture and TMD

A comfortable balanced bite results in even and equal pressures across the jaws and bones of the skull. The muscles are able to enjoy a relaxed posture and generally avoid the discomfort that accompanies muscle spasm and pain. Muscles, joints and teeth must work together in harmony and with a balance that prevents the nervous system from causing the muscles to overwork trying to avoid an unpleasant posture or position.

The muscles that control chewing, talking, and swallowing are all connected through a “postural chain” to your neck and back muscles, and must work together in balance and without stress. When this balance is interrupted, muscle tension increases as the nervous system tries to avoid further hurt or injury and at the same time allow the normal function to proceed.

When muscle imbalance occurs in the jaws because of a bad bite, there is a natural, compensatory chain reaction through the connected postural muscle groups of the head, neck and shoulders. Soon, these other muscles can be called upon to help balance any offsetting force. The result? Poor posture, back aches, muscle spasms, and headaches.

As a footnote you might be asking “Well okay, if this is true, then why doesn’t everybody else have problems?” Or, “Why are my problems so much worse (or better) than someone else’s?” The answer: Everybody has different “goalposts”, different hereditary capacities to adapt. If you have narrow tolerances you have less tolerance for stress and are more readily affected by even slight variations from “normal.” Wide “goalposts” mean that you can tolerate or withstand a lot and not have it spill over the edge to become symptoms or problems.

However, the absence of pain or problems does not in and of itself mean that you don’t have an underlying problem. Also, when symptoms stop, as in - “my jaws used to pop but not anymore” - this does not mean that the problem has gone away.

Proper Diagnosis – A Neuromuscular Approach

There are many hidden and underlying factors that can influence a proper diagnosis and treatment of headaches, TMD and jaw joint problems. To avoid unnecessary expense and sometimes a lifetime of needless misery, we believe it is very important that you receive the correct diagnosis and are treated by the right expertise and training. This often requires a well coordinated multi-disciplinary team approach, with the dentist “quarterbacking” the process. This is because only a dentist can properly evaluate, change or treat the dental and jaw relationship. Only a dentist can change the relationship of the jaw to the base of the skull, and thus affect the comfort and balance of the muscles which hold it in a sling and link it functionally with the neck.

Neuromuscular Dentistry is the term which accurately describes the training necessary to identify and treat these complex disorders of the jaw joint and associated muscles of the jaw, head and neck. The question can be put “Where would the muscles and jaw joint want the jaw and teeth to be positioned when the muscles are in their best physiological rest position?” Ignoring this question and its answer has profound implications. When your individual adaptive abilities are exceeded, or when the affected structures suffer cumulative stresses to the point they can’t take it any more and start breaking down, then symptoms and disability can set in.

The neuromuscular approach to dentistry goes beyond the examination of teeth, and gums. It goes beyond “tooth carpentry”. It recognizes the role that posture, muscles and the nervous system plays in the comfort and function of the jaw, the neck and the head. It is about being a “doctor of the mouth.”

Like gears in a machine, the teeth must fit together comfortably and in a balanced position with the muscles and jaw joint, so that when everything is fit together, the muscles are not tense or in spasm, and the jaw joint is not strained or compressed.

The lower jaw must fit or relate properly with the base of the skull. This important relationship is often overlooked by traditionally trained dentists and health professionals. Rather than asking the muscles what they “think” of the dental and jaw relationship, they rather focus on the teeth and expect the muscles to adapt and accommodate to the dental relationship. From the neuromuscular position, nothing could be further from the truth.

Similar to gears working together in a machine, the teeth and the jaw joint must be in harmony with each other and with the muscles that hold them together with the skull. It is when this balance is disrupted, or when the neurology gets “excited”, or when damage occurs to the joint, or when the muscles are not “happy”, that problems arise.

The Diagnostic Method

Neuromuscular dentistry uses modern computerized diagnostic methods to accurately read the muscle activity of our neck and jaw muscles, and to find that jaw position which is most ideal for keeping the muscles comfortable and the jaw ideally supported.

Most people’s dental bites are not perfectly balanced, to one degree or another. In most TMD cases there is a tug-of-war between teeth, muscles and the jaw joint. Teeth want to fit together in one position and your muscles and jaw joint want a different position. When there is a difference between what the teeth want and what the muscles want, the muscles wind up with a higher level of electrical activity (muscle tonus) as it struggles to find a stable position. This electrical activity can be measured and evaluated on a computer. Electronic instruments provide important information and clues about the true nature of your muscle and your jaw position, and have only recently been improved enough to allow these measurements to be seen on the computer in real time.

It requires long and sophisticated training to understand the many faces and nuances of TM Joint problems, and it requires having the latest of modern computer and electronic instrumentation to fully diagnose and optimally treat complex muscle and jaw posture problems. It is important to also have accurate and thorough information that comes from a hands-on evaluation of the jaw joint and the dental occlusion or bite, and from understanding the history of the problem.

For further information you can visit www.leadingdentists.com or call Dr. Ostler and schedule a visit to determine what more can be learned about your condition. With this information you will be able to make the right decisions about effective treatment options and hopefully begin a new life of pain free living.

To view a report on headaches click here.

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