Screening and Diagnosis
Dr. Steed will screen for signs and symptoms. She will:
- Review patient medical and dental history, including medications recently taken as well as other involved health care providers
- Determine how long the signs and symptoms have been present
- Determine the location of signs and symptoms present in the head, ear, jaw, and neck
- Determine if there has been injury to the jaw
- Assess the impact of dental treatment or surgical intervention such as intubation
- Listen for any sounds the TMJ makes through palpation, use of the stethoscope and use of the Doppler
- Measure the range of motion of the jaw including lateral movements
- Examine the bite to reveal abnormalities in the alignment of the teeth and in the movement of the jaw
- Palpate the muscles of the head, neck, face and involved ligaments and tendons
Due to the variance in development of anatomic structures involving the teeth, jaws and head, together with the many varied problems which may be involved with TMD, a thorough examination with appropriate tests, conducted by a doctor with advanced training in TMD, is essential in determining a proper diagnosis. Once this step is accomplished, proper treatment may be provided in an attempt to resolve the problem and to alleviate or greatly reduce the suffering. In doing so, permanent deterioration may be avoided.
Dr. Steed believes it imperative to begin with the most conservative and noninvasive treatment first. Inasmuch as Dr. Steed's vast experience has shown that only 2% of patients require surgical intervention, it is only logical to proceed with conservative, reversible treatment first, with surgical intervention reserved as a last resort – after all else has failed.
Aside from requesting the avoidance and overuse of the jaw, one or more of the following treatments may be recommended:
Phase I Treatment
- Medications. To reduce inflammation and lessen pain, the recommendation may be made to take aspirin or another non-steroidal anti-inflammatory drug such as ibuprofen (Advil, Motrin, etc.). Liquid gel anti-inflammatory medication often acts rapidly. Muscle relaxers are sometimes indicated depending on the intensity of the muscle pain/myalgia. Many patients already take medication prescribed by their MDs/DOs; this must be taken into consideration before other medication is prescribed.
- Heat or cold. Applying warm, moist heat to the facial muscles or applying ice directly to the site of the TM Joint may provide temporary relief. Never apply heat to the TM Joint since it can encourage additional inflammation.
- Behavior Modification. Motions that aggravate the problem such as biting hard into food, yawning, or sleeping face down can aggravate the TMJ. Poor posture, chewing gum, pencil biting, nail biting, etc. are also aggravating factors that can be modified with behavioral changes.
- Appliance. If the TMJ is misaligned, Dr. Steed may recommend a specially made acrylic composite orthotic (appliance) to be worn over the teeth to help align the upper and lower jaws. This will decompress the joints to allow for recapture of the dislocated discs, place the joints in their correct position and thereby promote healing and stabilization by scar development and/or the recapturing of the discs. This should help to balance the muscles of the head, neck and face. The goal of the appliance is to decrease or eliminate the pain, improve the function of the TMJs by reducing or eliminating the popping and clicking and/or decreased jaw range of motion limitation, such as locking. Another goal of wearing the appliance is to prevent further escalation of the active TMJ dysfunction. The TMJ appliance is often called a MORA, which stands for “mandibular orthopedic repositioning appliance”, since it orthopedically repositions the lower jaw to realign the TMJs.
- Night guard appliance. If night time teeth grinding exists, a night guard appliance, either semi-soft or firm, inserted over the teeth, can help prevent damage from grinding which can cause excessive tooth wear.
Phase II Treatment
- Corrective dental treatment. Depending on the examination findings, it may be recommended that the biting surfaces of your teeth be balanced through the replacement of missing teeth with crown and bridge work or crowns at proper height to support the mandible long term. Also replacement of missing teeth with partial dentures, new complete dentures, or implants providing the proper stabilizing position for the mandible may be necessary to stabilize the mandible long term.
- Orthodontia. Sometimes orthodontia is required after symptoms have subsided and the jaw is balanced. Orthodontia stabilizes the bite and the supporting muscles of the face and jaw and holds the TMJs in a proper position. This is done by orthodontically realigning the teeth to support the mandible long term.
- Arthrocentesis. This procedure, usually provided by an oral surgeon using IV sedation, involves insertion of a needle into the TM Joint so that medication can be added into the TMJ capsule. This is to attempt to break adhesions and physically realign the discs while reducing inflammation within the joint.
- Surgery. If none of the above approaches prove successful, consideration may be given to surgical intervention. However, the need for such surgery is rare. Arthroscopic surgery is utilized to remove tenacious adhesions and attempt to realign the discs if the arthrocentesis is not successful. On rare occasion, reducing the height of the condyle (ball of the TMJ) to allow proper disc placement or orthognathic surgery to realign the jaws may be indicated. Less than 2% of TMD patients require surgery.
Depending on the complexity of the condition, some patients may require prescription medications, physical therapy modalities, counseling/biofeedback together with referral to other health care professionals. Fortunately, if early treatment is instigated, a very small percentage of afflicted patients require surgery, although some do require diagnostic/therapeutic injections.
Approximately 20 to 30% of TMD patients require stabilization therapy in the form of Phase II Treatment such as orthodontia (braces), crowns (caps), crown and bridges, partial dentures, complete dentures (if the patient has no teeth - edentulous) or possibly a combination of these approaches. However, the greater majority of patients need no further treatment or require only night time wear of a night guard (appliance), if they clench or grind their teeth during sleep. Occasionally patients need to wear the intraoral appliance during sports activities due to the physical exertion to the muscles surrounding the jaw-complex and hence the jaw-joint itself.