Medical Management

Sometimes it seems like the way the symptoms are managed depends on where the elevator stops in the medical/dental building. Various supportive treatments work by enhancing the body’s natural adaptive capacity. Muscle treatments often provide short-term relief. Medications are widely used to relax the jaw muscles and reduce inflammation in the TMJs. Oral appliances are made by dentists to protect the teeth from the effects of grinding and clenching.

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).

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, after the initial inflammation stage, most TMJ disorders are chronic conditions rather than acute injuries, and they need rehabilitation rather than rest.

BOTOX is one way to temporarily 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, the failure of which is central to the root cause of TMJ disorders. Therefore, while Botox can relieve some TMJ disorder symptoms in the short run, it can also exacerbate the 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 carries the mandible into the pharyngeal airway.

POSTURAL WORK - helps, because the mandible is an integral component of the head posture mechanism, and the temporalis muscles are primary postural muscles. As a result, forward head posture can cause backward mandibular posture, just as backward mandibular posture can cause forward head posture.

TRYING TO RESTORE PROPER TONGUE POSTURE is a favorite technique of some physical therapists (the Rocabado school), some myofunctional therapists, and some orthodontists (Orthotropics), because they believe that many TMJ disorders are due to low tongue posture. The tongue should rest up high in the palate with its tip up against the front of the palate just behind the upper front teeth; however, in some people the teeth do not leave enough room for the tongue to rest at the front of the palate.

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, normal healthy TMJs often acquire very different shapes on the right and left sides, causing very asymmetrical opening and closing pathways that signify no pathology. For example, in patients with asymptomatic reducing disk displacement, the lower jawbone typically shifts to one side before returning to the midline during opening. In patients with non-reducing disk displacement, the lower jawbone shifts progressively to one side during opening. In these situations, 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 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 other muscle related health problems.

TREATING A DAMAGED TMJ - is appropriate when a TMJ is in the early inflamed stage, usually causing severe pain on forceful biting. However directly treating that TMJ is not appropriate after it has already healed and is no longer causing or contributing to the production of symptoms. The inflammation that indicates a need for direct treatment of the joint can be visualized on MRI (effusion), but not on X-ray. Therefore a decision that a TMJ needs surgery should not be based on X-ray.

TMJ INJECTIONS - 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) is injected to increase viscosity of the joint fluid. Prolotherapy injects a chemical irritant into ligament attachments to try and stimulate localized fibrosis. Recently injections of platelet rich plasma (PRP) or platelet rich fibrin (PRF) 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. In the near future, mini implants in the condyle will probably enable surgeons to reposition dislocated TMJ disks, but not yet.

CONTINUOUS PASSIVE MOTION

Joint surfaces get their circulation from the rubbing of the cartilage, which drives out fluids from areas under compression, and then draws in new fluids when the compression moves on to a different area. This functionally generated circulation process, known as weeping circulation, was discovered when a researcher put rabbits with injured hip joints on a machine that slowly and continuously moved their legs and found that they healed twice as fast as normal. To try and mimic that success, some companies have tried to design machines that similarly provide continuous passive motion for simple joints like knees and elbows; but the machines are expensive and lack the variable range of motion that most joints require. One was marketed for TMJs, but it was difficult to use. A simple way to provide functionally generated circulation for most joints at home is by using rubber straps like bicycle inner tubes to create continuous almost-passive motion. For the TMJs, the only way to apply continuous 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 JAW MUSCLES - After the inflammatory phase is resolved, the jaw muscles produce most of the symptoms in TMJ disorders, and there are many ways to treat them. Treatment must include the neck muscles, because these muscles don't function separately. Chewing involves your neck muscles, and moving your head involves your jaw muscles. Short-term treatment involves restoring circulation and stretching contracted muscles to restore their normal resting lengths. Long-term treatment involves providing your jaw muscles a healthy bite table for them to rest on and exercise against.

THE PROBLEM - Muscles become sore when their background resting tightness, or tonus, becomes too high to allow adequate resting circulation, causing 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, that drainage is assisted by functional forces, which alternately compress and release the veins, which have one-way valves that turn the alternating compression and release into a pump. However, in most of us, chewing no longer provides sufficient functional circulation to keep our jaw muscles healthy, so jaw muscle health relies on good resting circulation, which requires a low resting muscle tonus of about one percent of maximal voluntary contractile force. Higher muscle tonus compresses the capillary beds, which prevents adequate drainage of waste products. There are two common causes of chronically tight jaw muscles, and they work cumulatively.

STRESS - causes jaw muscle tightness, because it increases overall postural muscle tightness, and the jaw muscles are postural muscles. The jaw muscles are also especially sensitive to stress due to their unique anatomy. In most areas of the body, the bones are held between muscle groups of about equal size, so increasing postural tonus does not move the bones – it just holds them more tightly. However, in the jaw system, the closing muscles dwarf the opening muscles, so increasing the tonus holds the jaw further closed, sometimes with the teeth touching, which triggers chewing reflexes that result in clenching or grinding. When a muscle has already been operating at borderline resting circulatory levels due to chronic tightness from an inflamed TMJ or an unstable bite; even a slight increase in resting muscle tonus due to increased central nervous system stress can 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.

AN UNSTABLE OR DISPLACED BITE is another common cause of chronically tight jaw muscles. Unstable joints trigger increased tonus in the muscles which cross that joint. The bite functions like a joint between the jawbones, so unstable bites trigger increased tonus in the jaw muscles. A displaced bite produces sustained uneven jaw muscle tonus in order to hold the mandible in a posture that fits the displaced bite position.

MUSCLE CONTRACTURE can occur after chronic tightness has caused shortening of muscle fibers. They lose 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 held in contact or even clenched.

TRIGGER POINTS often occur in chronically tight muscles, when small pools of waste products accumulate in locations of 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 evoked and also treated by forceful compression of the site using a finger, knuckle, or elbow. The greater the force used, the more sustained the relief. Trigger points can be injected with novocaine or saline. The immediate pain is intense, but the relief can last a long time. Vibrating massagers can probably also help flush out waste products.

STRETCHING postural muscles can reduce their tightness and provide short-term relief, but actual postural correction requires shifting your resting weight-bearing stance; which requires stretching out the muscles that held your old weight-bearing stance and strengthening the muscles that are needed to maintain an improved weight-bearing stance. All the body’s postural muscles are involved, because the jaw and neck muscles are connected with the other postural muscles in long myofascial chains running up and down the length of the body. A change in the resting length of one muscle affects all the other muscles in the chain, and a change in the resting length of a chain induces a change in the resting length of the opposing chain. Stretching is especially important for people with strong muscles. To be effective, it should include the tough sheets of fascia that bind all the muscles together into long functional units (AKA myofascial release).

ICING WITH STRETCH is a good way to restore normal resting lengths to tight jaw muscles. To stretch the jaw muscles, prop the jaw open with a block such as a wine cork or a piece of wood held vertically between your front teeth. At the same time, ice the jaw muscles by holding freezer packs or bags of frozen vegetables against your cheeks and temples. The icing with stretch is maintained for a few minutes or until it becomes uncomfortable. Then the block and ice are removed, the mouth is closed, and a hot wet towel (microwaved) is used to bring in warmth and fresh blood. You can go back and forth from ice-with-stretch to heat-with-relaxing many times while watching a movie.

ATTITUDE influences posture by selectively altering resting muscle tonus. 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 alters resting tonus to make the chest sink inward, the head hang downward, and the shoulders slump. It can make the mandible move so far backward that it impinges on the airway passage, which triggers an airway protective response that advances the hyoid bone to reduce airway flow resistance, producing the lump in the throat that often accompanies grief. Conversely, feeling proud, angry, or determined alters resting tonus to cause thrusting of the chest, standing tall, and jutting the mandible.

PASSIVE PHYSICAL SUPPORT mechanically realigns your body for long enough to impact resting posture. Most seats on planes, trains, and buses hold the head forward. Sleeping supine on a soft mattress such as a waterbed, air mattress, or memory foam produces forward head posture by allowing your body to sink down at its center of mass (usually at the hips or abdomen). In contrast, a firm mattress or a futon pushes your spine towards a straight axial alignment that supports your legs and head in the same plane as your hips, and shoulders.

PILLOWS influence your posture by the way they align your head. When supine, your pillow should allow the back of your head to rest in contact with your mattress. Neck support can be provided by a U shaped pillow (such as a travel pillow), a pillow with a hole in the middle, or a rolled-up towel under your neck, which can be combined with a pillow on each side of your head so that you can easily roll onto either side where the support from the pillow is roughly as thick as the distance between your ear and your shoulder.

ACTIVE PHYSICAL SUPPORT - uses your muscles to improve your skeletal alignment. One way to do that is 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 an ideal alignment, or your muscles will rapidly become exhausted. They need exercises that pump blood. You can selectively strengthen the muscles that you need to improve your posture by 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 a head rest in a car or your hands held behind your head. Incorporating movement, such as simultaneously rotating your head slowly from side to side, also provides weeping lubrication and circulation at the joint surfaces. Strengthening the jaw and neck muscles requires also strengthening the muscles of the shoulders and back, which form their base of operation, because these muscles all function together.

EXERCISES - used to rehabilitate muscles for health, rather than maximal strength, should be repeated in rhythmically alternating contractions of about a second each to mimic functional activities such as chewing, walking, climbing, hitting, and shaking; in which two opposing muscle groups alternate firing and relaxing in a way that pumps circulation.

COMBINING stretching and strengthening can be accomplished by exercises such as Yoga, Tai Chi, or pulling yourself upward using overhead bars in a technique I call variable rhythmic distraction. 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 it 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. In this manner, you can exercise your arms while decompressing your spine in a way that enhances circulation to your intervertebral joints.