Current Treatment
With misunderstanding the causes of TMJ disorders has come a multitude of ineffective treatments and misinformation. For example, disclusion time reduction (DTR) and neuromuscular dentistry (myotronics) are non-biologic concepts that were simply constructed to market equipment. Botox has become a popular management tool, because it can sometimes relieve chronic symptoms by temporarily breaking up the symptom generating cycle; even though it weakens the jaw muscles, which limits their ability to regulate subsequent (adult) facial growth, which is at the root of most TMJ disorders. NTI and similar "anterior only" or "anterior jig" appliances are used widely and non-specifically, because they sometimes relieve headaches by reducing jaw muscle forces during nocturnal bruxism, just as Botox and front flat bite plate appliances do. Products such as Doppler or joint vibration analysis of the TMJs, jaw velocity analysis, sonography, thermography, surface EMG, the myotronics and BioPak jaw tracking systems, and TEK scan bite analysis look impressive to patients and make dental exams seem thorough, but they have little to no clinical usefulness. One goal of this website is to dispel the widespread misinformation associated with the marketing of these products. Some of the most commonly believed myths regarding TMJ disorders are described in MISCONCEPTIONS.
Misinformation has created so much confusion in this field that the dental associations have been unable to agree on regulations or even guidelines for treatment of TMJ disorders, except to be cautious. Most experts advocate one type of oral appliance for nearly all their patients, even though different types of appliances have completely different effects. Well meaning dentists often don't know what to believe. Therefore another goal of this website is to explain the causesof these disorders so dentists can use their common sense and whatever tools are available to them to effectively treat their patients.
One result of the lack of regulation is that patients often get treatment that is not appropriate for their condition. Many patients with X-rays that show extensive degeneration of the TMJs get treatments such as surgery and steroid or PRP injections, which are directed at the TMJs; even though their TMJs healed long ago and are no longer causing or even contributing to their symptoms. Many patients who have jaw muscles with excessive tonus due to reflex protective jaw muscle bracing in response to an inflamed TMJ receive jaw muscle treatments to try and loosen the tight jaw muscles without first protecting the inflamed joint to stop the protective muscle bracing that is producing the tightness, which is like massaging the sore tired leg muscles of someone who is walking around on a swollen ankle without first providing an ankle brace.
Thousands of adult patients every year undergo lingual frenectomy to treat tongue tie, which is diagnosed by noting that the patient cannot hold the tongue against the palate during wide opening, which is beyond the tongue's normal range of motion and therefore represents no pathology. It's easy to understand that babies who do not get to nurse on a natural breast may have a tongue that develops due to a limited range of motion; and tongue tie is a well known problem in babies who cannot nurse or in children who cannot pronounce letters like R; however, in adults who can speak normally and lick their lips but have low tongue posture, the cause of low tongue posture is the narrow palate, not a tight frenum; and the only benefit of lingual frenectomy is to better enable natural cleaning of the teeth with the tongue.
BITES - The biggest source of confusion regarding the treatment of TMJ disorders has always been bites. Most dental authorities today consider any bite treatment to be contraindicated, because it is not evidence-based. However, any evidence-basis for bite treatment would require a way to measure the functional aspects of bites, and dentistry has never had that. It's the inability of dentistry to understand the bite, rather than the lack of importance of the bite in the pathogenesis of TMJ disorders, that has prevented the widespread effective treatment of TMJ disorders. The bite functions as a joint between the upper and lower jawbones, and its articular surfaces (the upper and lower bite tables) can profoundly influence the health of the whole jaw system and the growth pattern of the face; but dentists are generally afraid of altering the bite in any way; because dentistry has failed to understand the functional role of the bite. As a result, we allow a large number of health problems to develop in growing children and adolescents due from strain between misfitting jawbones, because we don't even try to prevent them; and they produce a wealth of symptoms in the TMJs, airway passage, and the postural system during adulthood. A general understanding of how our bites are supposed to work in health and their role in TMJ disorders, sleep apnea, and related problems is explained in the five ETIOLOGY chapters; and the clinical use and misuse of bites is described in BITES: CURRENT CONCEPTS.
APPLIANCE DEPENDENCE becomes a problem after an oral appliance has been worn full time for so long that the teeth of the opposing dental arch have shifted to fit the surface of the appliance rather than the natural teeth. Then, removing the appliance leaves the patient without a bite. Full time wear of any oral appliance should come with an exit plan other than sending the patient to an orthodontist, who will probably just straighten their teeth.
LOWER NIGHTGUARDS can also destabilize bites, especially during times of stress when nocturnal bruxism increases, because nocturnal bruxism that is forceful enough to depress the teeth usually occurs when the mandible is located posteriorly; which prevents the application of axially directed forces to the front teeth, which can allow them to supererupt (extrude) and become longer. In this manner, lower nightguards can increase overbite, which drives the mandible further posteriorly, which forces the condyles against the posterior borders of the TMJs, which causes dislocation of their articular disks. Dentists should only make lower nightguards for people with class 3 malocclusions.
UPPER NIGHTGUARDS rarely destabilize bites, unless they fail to cover the second molars; but they are still designed to protect the teeth rather than the TMJs. When they provide relief of TMJ disorder symptoms, it is not from protecting the TMJs but from providing a tall stable bite platform that stretches the jaw muscles.
ESTHETIC ORTHODONTICS, in the form of braces, usually waits for the second molars to erupt and then uses pre-fabricated arch wires locked into brackets located on the exact center of each tooth to drag the teeth slowly through the bones until they achieve the same perfect curve as the arch wires. The upper teeth can be aligned perfectly, and the lower teeth can be aligned perfectly, however there is very little ability to control where they fit together, a key feature in the development of TMJ disorders. Even the mandibular midline cannot be well controlled - it is often left displaced a few mm to one side. In the short term, each tightening of the wires can diminish nocturnal bruxism, because the soreness it produces in the teeth automatically reduces jaw muscle activity for about two weeks. However, weakening the jaw muscles can also prevent them from regulating jawbone growth, which is at the root of TMJ disorders. TADs (temporary anchorage devices) now allow orthodontists to intrude the supererupted teeth that produce growth restricting overbites.
FUNCTIONAL ORTHODONTICS has been popular in Europe for decades, but recently some variations of functional orthodontics have been rebranded and marketed in the US with misleading claims. For example, ALF (advanced lightwire functional) appliances, are bent wire appliances that employ low forces for long periods of time. Proponents claim, "they allow for a greater range of neurological regulation to occur, especially through the cranial nerves and the autonomic nervous system." Light gentle forces are certainly more biologically acceptible than strong forces, but forces from wires cannot regulate neurologic activity, and ALF appliances are mostly tooth straightening devices with a few functional effects. DNA, RNA, and Homeoblock appliances are traditional palate expansion appliances that are marketed as epigenetic; which is misleading, because there is no evidence that straightening the teeth or widening the palate in an adult will lead to straighter teeth or wider palates in their offspring.
NON-DENTAL TREATMENT - Physicians and general dentists usually suggest a soft food diet, because the standard medical model for an acute injury is rest of the affected part, even though most TMJ disorders are not acute injuries but chronic conditions, which require rehabilitation rather than rest. Some physicians manage TMJ disorders by injecting the TMJs with steroids or platelet rich plasma or fibrin. Chiropractors and physical therapists rehabilitate muscles using various electrical and thermal modalities as well as exercises and stretches. Chiropractors make cervical adjustments which can improve mandibular posture until the old habitual bite drives the mandible back to the one location where all the teeth fit. Myofascial release and forceful compression of trigger points can reduce muscle tightness. Applied kinesiology attempts to determine the ideal bite position by measuring postural muscle resistance. Massage can flush out capillary beds to improve resting circulation in muscles. Cranial and craniosacral treatments use light manual pressure to manipulate the skull and spine in order to free up blockages to cerebrospinal fluid circulation, as described in a separate file of the same name under the tab TREATMENTS.
A SELF LIMITING CONDITION - Fortuntately, TMJ disorders are self-limiting problems because of natural adaptation. Longitudinal studies of tens of thousands of untreated patients have shown that their symptoms disappear over time, especially by middle age. Older people experience postural muscle tightness extending to the jaw muscles, difficulty chewing due to a misfit between their bite and their TMJs, or ear symptoms that persisted from earlier injuries; but they only sustain TMJ inflammation when maintained by extreme loss of vertical dimension (usually in dentures), a systemic arthritis that attacks their TMJs, or complications resulting from failure of a previous open TMJ surgery.