Conventional Medical Treatment

There are a wide variety of medical treatments employed by physicians, physical therapists, and other health care professionals to treat people with TMJ disorders. Many of them are also employed by dentists.  Sometimes it seems like the treatment a patient receives depends on where the elevator stops in the medical-dental building.

The MOST COMMON way to treat TMJ disorders is to “manage” the occasional bouts of severe symptoms by means of short term and supportive therapies, ranging from medication to meditation. Some management techniques, such as nutritional counseling and stress relief, work by enhancing the body’s natural adaptive capacity. Other management techniques work directly on the jaw muscles.  Even closed surgeries such as arthroscopy and arthrocentesis are sometimes used as management tools.  

ANTI-INFLAMMATORY MEDICATIONS can reduce inflammation in the TMJs much like they can reduce inflammation in other injured joints.  The medications can be taken in pill form, injected into the TMJs, or applied topically on the skin over the TMJs and electronically drawn into the skin using iontophoresis.  However, reducing inflammation without addressing its cause usually just provides short term relief.

REST of the affected part is the standard medical model for acute injuries, therefore many dentists and doctors advise patients with TMJ disorders to avoid chewing gum or tough foods; however most TMJ disorders are chronic conditions rather than acute injuries, and they need rehabilitation rather than rest.  Rest can provide some relief during a severe bout of TMJ disorder symptoms, but even acutely inflamed TMJs usually benefit more from mechanical distraction combined with passive movement than from lack of use.  For example, it usually feels better to rest your jaw on food or even a piece of chewing gum on the side of the inflamed TMJ than to not bite at all.

JAW MUSCLE TREATMENT can improve resting jaw muscle circulation and thereby provide some quick relief for muscular symptoms when the TMJs are not inflamed.  Even though muscles rarely initiate problems, jaw muscle tightness and contracture that result from chronic TMJ inflammation frequently become self-sustaining pain generating conditions that can persist long after the inflammation has resolved.  Subsequently, treating the jaw muscles with a variety of modalities can provide lasting relief.  These therapeutic modalities include stretching the muscles to restore normal resting lengths, injecting or forcefully compressing (mashing) trigger points or knots located within tight bands in the muscles, icing muscles while stretching them (spray and stretch), deep heat (ultrasound or laser), applying medication on the overlying skin and driving it in with iontophoresis, transcutaneous electrical nerve stimulation (TENS) which temporarily enhances local circulation, and high voltage electrogalvanic stimulation (EGS) which treats trigger points.  In some patients, the jaw muscles may be strengthened by exercises.  In other patients the forces applied by the jaw muscles during nocturnal bruxism are diminished by a front flat plate appliance or deep relaxation.  

However, focusing on the jaw muscles when one of the TMJs is inflamed only yields short term relief, because the inflamed joint causes the jaw muscles to tighten up again after any treatment.  The effect is like massaging the leg and back muscles of someone who has an untreated inflamed ankle.  Walking on the damaged ankle automatically causes all the muscles in the area to hold themselves tight and limp to protect the inflamed ankle.   Treating those tight muscles without first eliminating the inflammation feels good but has little lasting effects.  Similarly, when your TMJ is inflamed, your jaw muscles automatically hold themselves tight to protect that TMJ.  Treating that muscle tightness while the joint is still inflamed invites relapse.

BOTOX injection reduces jaw muscle forces by temporarily weakening them.   It has been shown to have some pain relieving properties in experimental injuries to rats, and in humans it can provide three months of relief for some cases of chronic migraine and unusual neuropathic pain conditions involving muscle spasm, such as oromandibular dystonia or cervical torticollis; but it has not proven effective in treating most TMJ disorders, because so few TMJ disorders are caused by excessive jaw muscle strength.  Weakening the jaw muscles diminishes the forces they can apply to the TMJS during nocturnal bruxism, but those forces are rarely the ultimate cause of the TMJ problem.  In fact, TMJ disorder patients tend to have weaker than normal jaw muscles.  Further weakening the jaw closing muscles further reduces their ability to regulate subsequent facial growth, which is at the root cause of most TMJ disorders.  For that reason, Botox is especially problemmatic in people with backwardly rotating lower jawbones, because weakening the jaw muscles exacerbates the backwardly rotating growth.  Thus it may provide short term relief, but it worsens the problem in the long term.
 

POSTURAL TREATMENT is used to treat TMJ disorders by a health practitioner, usually a physical therapist or a chiropractor, who teaches patients how to hold their heads and shoulders back.  The lower jawbone is an integral part of the postural system, as explained in lay language in THE ROLE OF BODY POSTURE under TMJ DISORDERS and in technical language in OCCLUSION AND POSTURE under FOR DOCTORS.   Postural improvement can certainly improve lower jawbone posture and therefore also the course of a TMJ disorder, which is dependent on lower jawbone posture; however the posture of the lower jawbone is primarily under the control of the bite.  Without changing the bite, any therapeutic change in lower jawbone posture is bound to relapse, along with all the other postural improvements that are involved in the attempted change.

TRYING TO RESTORE PROPER TONGUE POSTURE   There are many practitioners who treat TMJ disorders which are characterized by narrow palates by teaching patients to hold the tongue tip up against the front of the palate.  In these patients, the tongue has acquired a posture that is low in the mouth, because there was insufficient space in the palate.  However, the low tongue posture is an effect of the pathology rather than a cause of it.  The palate must be widened before the resting posture of the tongue can be altered.

TRYING TO RESTORE OPENING AND CLOSING SYMMETRY    There are many practitioners who treat TMJ disorders which are characterized by asymmetrical jaw opening and closing patterns by training the patients to open and close in the midline using a mirror.  Although the notion of restoring symmetry is appealing, there is no evidence that it is useful for relieving the condition.  The two TMJs are shaped very differently, even in healthy people, causing asymmetrical lower jawbone pathways during opening and closing.  In reducing disk displacement, the lower jawbone typically shifts to one side before returning to the midline during opening.  In non-reducing disk displacement, the lower jawbone often shifts progressively to one side during opening without returning to the midline.  Yet, in these situations, it is the pathology that produces the asymmetry rather than the asymmetry producing the pathology, therefore attempting to restore symmetry is treating the effect rather than the cause.   

JOINT INJECTIONS in the TMJs work like they do in other joints.  Anesthetic injections are useful diagnostically.  Steroid injections can provide quick relief of inflammation.  Hyalouronic acid has been injected into joints for decades and sometimes works for reasons we don't understand.  Prolotherapy injects a chemical irritant into ligament attachments in order to try and stimulate fibrosis.  Some studies have found it effective, but others have not.  In TMJ disorders, it is injected into the retrodiskal area where reactive fibrosis of the tissues could assist with pseudodisk formation.  
 
SUPPORTING GENERAL ADAPTIVE CAPACITY
Because most TMJ conditions are ultimately caused by an adult facial growth pattern that continually applies stresses to the jaw system, the presence of symptoms is determined largely by the ability to adapt to those stresses.  As a result, anything that impairs the body's overall adaptive capacity (such as stress, poor nutrition, or an unrelated disease or injury) can trigger or exacerbate symptoms, and anything that enhances the body's overall adaptive capacity (such as improved nutrition, meditation, exercise, or social support) can relieve symptoms.  A wide variety of health care practitioners can relieve symptoms by enhancing general adaptive capacity.
 
OPEN SURGERY of the TMJ is risky, because failures can be disasterous due to a build-up of scar tissue can prevent natural adaptation. Further surgeries are necessary to clean out the scar tissue, but the chance of eliminating the pain decreases with each successive surgery. For that reason, according to insurance company statistics, the primary indication for TMJ surgery is previous surgery, and even the oral surgery journals warn that open TMJ surgery should be considered a last resort. With so many different treatments available, having failed one type of non-surgical treatment is still not an indication for open surgery.  Unfortunately, there are still oral surgeons who only provide a simple nightguard before concluding that conservative treatment is ineffective and surgery is necessary.
 
CLOSED SURGERY
Arthroscopy and arthrocentesis are closed surgeries that don’t involve the same risk of failure as open surgery.  Instead of cutting the joint open, the surgeon inserts two little tubes which are used to irrigate the TMJ. Arthrocentesis employs tubes that are just large enough to flush out the waste products and inflammatory mediators.  Arthroscopy employs slightly larger tubes that can incorporate a fiberoptic cable for visualization and small instruments such as miniature cutters to remove scar tissue.  These closed surgeries can provide quick temporary relief of symptoms by flushing out the joint, however they do not create structural changes in the jaw system. If they are not combined with some orthopedic or behavioral changes that address the cause of the problem, the symptoms are likely to recur.