Medical Management

Most TMJ disorders today are "managed" using whatever skills are possessed by whoever treats the problem. It seems like the treatment a patient receives depends on where the elevator stops in the medical or dental building. Some management techniques, such as nutritional counseling and stress relief, work by enhancing the body’s natural adaptive capacity and thereby enabling it to adapt to the continuing mechanical strains produced by the dysharmonious jaw and facial growth pattern. Other management techniques, including the oral appliances commonly made by dentists to treat TMJ disorders, work by treating the tight jaw muscles produced by the dysharmonious jaw and facial growth pattern. Medications are widely used to relax the jaw muscles or reduce inflammation in the TMJs. The most common management techniques are described in more detail below.

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.

ANTI-INFLAMMATORY MEDICATIONS can reduce inflammation in acute TMJ injuries much like they do in other acutely 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 in (iontophoresis).

BOTOX is one way to diminish the forces used in nocturnal bruxism and thereby interrupt a pain generating cycle that includes nocturnal bruxism, but it also has the effect of weakening the jaw muscles, which are responsible for regulating facial growth, which is at the root cause of TMJ disorders. Therefore Botox can relieve some TMJ disorder symptoms in the short run, but it can also sustain the root problem in the long run. It is especially problemmatic in people with backwardly rotating jawbones, because weakening the jaw muscles increases backwardly rotating mandibular growth, which is a common cause of TMJ disorders.

POSTURAL TREATMENT affects TMJ disorders, just as TMJ disorders affect posture; because the mandible is an integral component of the head posture mechanism. However, the posture of the mandible is controlled by the bite due to reflex control mechanisms that were hard-wired in to protect the teeth. By controlling mandibular posture, the bite also controls the direction in which the jaws grow, which affects the posture acquired by the head and neck, which affects how the spine aligns beneath the head and neck to support their weight on its top end.

TRYING TO RESTORE PROPER TONGUE POSTURE is a favorite technique of some physical therapists (the Rocabado school) and some orthodontists (Orthotropics), who teach patients to hold the tongue tip up against the front of the palate, because they believe that many TMJ disorders are due to low tongue posture. Ideally the tongue should rest with its tip up against the front of the palate; however, the source of the low tongue posture is nearly always a palate that is too narrow to house the tongue, thus the palate has to be widened before the tongue can rest up higher where it belongs. In addition, the tongue muscles can't be strengthened without also strengthening the jaw muscles, because the mandible serves as the bone for the tongue, and the muscles of the area function as a unit.

TRYING TO RESTORE OPENING AND CLOSING SYMMETRY Some practitioners treat people who have asymmetrical jaw opening and closing patterns by training them to open and close in the midline using a mirror. Although the notion of restoring symmetry is intuitively appealing, TMJs often acquire very different shapes on the right and left sides, causing asymmetrical opening and closing pathways in people with perfectly healthy jaws. For example, 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 shifts progressively to one side during opening. Yet, in these situations, it is the pathology that produces the asymmetry rather than the asymmetry that produces the pathology, therefore attempting to restore symmetry is treating the effect rather than the cause.

SUPPORTING GENERAL ADAPTIVE CAPACITY

Because most TMJ conditions are ultimately caused by an adult facial growth pattern that continually creates strains between the jaws, the presence of symptoms is determined largely by the patient's ability to adapt to those strains. 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, deep relaxation, exercise, or social support) can relieve symptoms. If you eat fast food, improving your nutrition can help your body adapt to the strains of TMJ disorders as well as many other health problems. Similarly, if you maintain a chronically high anxiety life style, anything that relaxes you can also help your body adapt to the strains of TMJ disorders as well as many other health problems.

TREATING THE TMJs - is appropriate when a TMJ is inflamed, but not once it has already healed and is no longer causing or contributing to the production of symptoms. The inflammation can be visualized on MRI, but not on X-ray. Therefore a decision that a TMJ needs surgery should not be based on X-ray.

JOINT INJECTIONS in the TMJs work like they do in other joints. Anesthetic injections are useful diagnostically. Steroid injections can provide quick temporary relief of inflammation. Sodium hyaluronate (Hyalouronic acid) has been injected into joints for decades and probably works by stimulating fibrosis. Prolotherapy injects a chemical irritant into ligament attachments to try and stimulate localized fibrosis. Recently injections of platelet rich plasma or platelet rich fibrin have been shown to institute healing responses in TMJs, sometimes combined with arthrocentesis.

SURGERY

Open surgery is rarely necessary and can lead to problems that persist long after the injured TMJ would have healed naturally. Arthroscopy and arthrocentesis are closed surgeries that don’t involve the same risk of failure. Instead of cutting the joint open, the surgeon inserts two little tubes 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 usually provide quick short-term relief by flushing waste products out of the joint; however, if they are not combined with some orthopedic or behavioral changes that address the cause of the problem, the symptoms are likely to recur. Open surgery including mini implants in the condyle will probably enable repositioning of dislocated TMJ disks in a few years.

CONTINUOUS PASSIVE MOTION

Animal experiments have shown that continuous passive motion can dramatically reduce healing time in synovial joints after injuries, because joint surfaces get their circulation from the rubbing of the cartilage by fluids getting expressed from each area when it gets compressed and then allowing fluids to get reabsorbed when the compression moves on to a different area. This functionally generated circulation process is known as weeping circulation. The process was first discovered in animal studies which used electric motors to move simply joints back and forth. To try and mimic that success, some companies have tried to design machines that use electric motors to provide continuous passive motion for simple hinge joints like knees and elbows; but the machines lack the variable range of motion that is required by more complex joints. A machine was designed to continuously move the mandible for treatment of TMJ injuries, but it was uncomfortable and not very effective. A simple home remedy to provide functionally generated circulation for most joints is using rubber straps to create continuous almost-passive motion. For the TMJs, the best way to create almost-passive motion is to lie face down on a massage table with your jaw hanging freely in the hole and use your hand to move your jaw around passively.

TREATING THE MUSCLES - can provide quick relief if there is not an inflamed TMJ.

Muscles develop chronic pain or soreness when waste products build up in their capillary beds. These capillary beds function like big sponges. The heart can easily pump new blood into them, but it cannot so easily suck the old blood and waste products out of them. In most areas of the body, the removal of waste products from the capillary beds is assisted by functional forces, which alternately compress and release the veins, which have one-way valves that turn the compression and release process into a pumping action. Agonists and antagonists alternate pumping during firing, with relaxation between firings to allow inflow of new blood. However, we no longer chew hard enough to provide sufficient functional circulation to keep our jaw muscles healthy, so good resting circulation during relaxation is critical to modern jaw muscle health. Resting circulation is very much affected by muscle tonus, probably because of the passive compression that the tonus applies to the capillary beds. Normally muscles maintain tonus in the form of a light contraction that is about 1 percent of a muscle’s maximal voluntary contractile force. When tonus increases to two or three percent of maximal voluntary force, the compression of the capillary beds interferes with their drainage through venous and lymphatic circulation. As a result, the waste products generated by metabolism accumulate in the tissues.

TRIGGER POINTS - are currently most often blamed on dysregulated motor end plates, but they are probably just small pools of waste products that have accumulated in a muscle with inadequate resting circulation. They are commonly described as pea shaped nodes that are exquisitely sensitive to manual pressure, and they can cause pain at distant locations in typical "pain referral" patterns, which can be treated by forceful compression of the site using a finger, knuckle, or elbow. The greater the force used, the more sustained the relief. There are many dentists and doctors who inject trigger points with novocaine or saline. The immediate pain is intense, but the relief can last a long time. The massage guns that have recently become popular are effective at treating trigger points by increasing rates of fluid exchange in the tissues and thereby facilitating the flushing of waste products from pockets where they have accumulated.

MUSCLE CONTRACTURE - When muscle tightness persists for long enough, the muscle fibers shorten anatomically in a process called contracture. They lose some of their resting length. If your jaw muscles are in contracture and you fall asleep in a chair, your jaw will not hang open very far. Instead, your teeth may be almost touching, fully touching, or even clenched together. Restoring healthy resting lengths in muscles under contracture requires stretching.

MUSCLE STRETCHING - can be accomplished by icing muscles while they are held elongated - icing the jaw muscles by holding ice packs or bags of frozen vegetables on your cheeks and temples while holding your jaw propped open on a block such as a wine cork or a piece of wood held between your front teeth. It should be propped fairly wide open, but it doesn't need to be forced way open, especially at first. The icing with stretch is maintained for a few minutes or until it becomes uncomfortable. Then the block is removed, and the ice is replaced by a hot wet towel (microwave) on a closed relaxed jaw. The heat will feel good and bring in fresh blood after the ice has contracted the fibers, and the ice will feel good after the heat, so the two modalities (ice with stretch, and heat with relaxing) can be alternated many times while watching a movie.

STRESS - can worsen a muscle related condition in any part of the body by increasing resting muscle tonus all over the body. When a muscle has already been operating at borderline resting circulatory levels due to chronic tightness from an unstable joint such as an inflamed TMJ or an unstable bite; even a slight increase in overall central nervous system stress can raise muscle tonus high enough to impair resting circulation and result in accumulation of waste products, which causes pain. For that reason, a period of increased central nervous system stress often precedes the onset of postural muscle symptoms, and relief can usually be obtained from stress lowering measures like relaxation, meditation, humor, spiritual inspiration, or feeling loved.

ATTITUDE influences posture by selectively altering resting muscle tensions, therefore attitude can be used to treat muscles. The motor end plates, where the electrical signals from the brain reach the muscles, are anatomically extensions of the brain, so the state of the brain determines which muscles are held tightly and which are held loosely. Feeling sad makes the mandible move backward, the chest sink inward, the head hang downward, and the shoulders slump. The mandible often moves so far backward that it impinges on the airway passage, which triggers a protective response that pulls the hyoid bone forward, producing the classic lump in the throat. Conversely, feeling proud or determined causes forward thrusting of the chest, standing tall, and jutting the mandible, which can also be seen in facial expressions of anger or determination.

PASSIVE PHYSICAL SUPPORT affects muscle health by realigning your body alignment for hours at a time. Most seats on planes, trains, and buses have head rests that produce forward head posture. Sleeping on your back on a soft mattress such as a waterbed, an air mattress, or memory foam also produces forward head posture, because it allows your body to sink down at its center of mass (usually at the hips or abdomen). A mattress made of simple foam rubber or a futon can reinforce good body posture by constantly pushing your spine towards a straight axial alignment that supports your legs and head in the same plane as your abdomen, hips, and shoulders.

Pillows influence your posture by the way they align your head. If they hold your head in forward head posture all night, you'll tend to walk around in forward head posture all day. When back sleeping, your head can be cushioned, but the back of your head should also be in contact with your mattress, with much of the cushioning under your neck rather than under your head. Neck support can be provided by U shaped pillows (such as travel pillows), a pillow with a hole in the middle, or a rolled-up towel under your neck combined with pillows on each side of your head so that, when you roll over to either side, your head rolls up onto a pillow that is roughly as thick as the distance between your ear and your shoulder.

ACTIVE PHYSICAL SUPPORT - you can use your muscles to improve your skeletal alignment by holding yourself as tall as possible. Both the anterior shifting of the head and the increased thoracic and lumbar curvatures that accompany it cause loss of vertical height, and restoring some of that height can restore some of the lost spinal support; however you can't just hold your skeleton in an ideal alignment, or your muscles will rapidly become exhausted. They need rhythmic exercises that pump blood and increase the tonus in certain directions. You can selectively strengthen the muscles that you need to pull you out of your old posture and into a better one by making an exercise of repeatedly allowing yourself to slouch and then pulling yourself back up into ideal posture. Also, you can selectively strengthen the neck muscles that you will need to reverse forward head posture by repeatedly working your head back against resistance, like that provided by a head rest in a car or your hands held behind your head, especially if you work it at different angles or while rotating it slowly from side to side. Dynamic exercises (involving movement) are generally healthier for joints than isometric exercises, because movement provides weeping lubrication and circulation at the joint surfaces. Strengthening the jaw and neck muscles also requires strengthening the muscles of the shoulders and back, which form their base of operation. These muscles are all connected, and they need to all be strengthened together.

Exercises used to rehabilitate muscles for health are different from exercises used to strengthen muscles for athletic performance, because they are designed to build blood supply. Rehabilitation exercises should be repeated in rhythmically alternating contractions of about a second each to mimic functional activities such as chewing, walking, climbing, hitting, shaking, etc; in which two opposing muscle groups alternate firing and relaxing in a way that pumps circulation. Each firing squeezes out old blood, and then each relaxation allows fresh blood back in. Each time one muscle group (agonists) fires, its antagonists relax. In this manner, healthy exercise rhythmically flushes tissues and pumps circulation. Guarding behavior in muscles, which is reflexively triggered to protect inflamed joints or unstable bites, interferes with this circulation by causing overlapping muscle firings (co-contraction) to protect joints by holding the bones more tightly.

STRETCHING is important especially in people with strong muscles. To have lasting effects, stretching also has to include the tough sheets of fascial webbing that bind all the muscles together into long functional units. This stretching, also called myofascial release, requires considerable force.

COMBINING stretching and strengthening of muscles can be accomplished by exercises such as Yoga, Tai Chi, or pulling yourself upward using overhead bars. Even if you don't pull yourself off the ground, applying some traction to your spine by pulling upward with your arms serves to distract the compressed vertebral segments. Doing that rhythmically provides accessory circulation at the joint surfaces, and doing it in a variety of positions and directions extends that circulation all around the joint surfaces. Variable rhythmic distraction is a technique in which you use any kind of overhead support (bars, door frames, or tree limbs) to rhythmically and repetitively pull up on your spine at various angles. In this manner, you can exercise your arms while using your arm strength to decompress your spine in a way that enhances circulation to the intervertebral joints.