TMJ Pain Relief

An extensive study has been conducted by ECRI, formerly the Emergency Care Research Institute, an independent nonprofit health services research agency with the main research campus in Plymouth, Pennsylvania. The study concluded that although 10 million Americans are estimated to experience clinically significant symptoms of TMD, treatment is often nonspecific and palliative, because the etiology of most forms of TMJ pain are not well established.

It has been estimated that the annual cost for treating chronic tmj pain is $32 billion and that the high cost of that treatment is directly related to the lack of relief to traditional medical treatment approaches. Consequently, there is a wide range of therapies that are used in treating patients with TMD, including pharmacotherapy, splints, intra-articular injections of lubricants or anti-inflammatory agents, arthrocentesis (puncture and aspiration of the TMJ using an inflow and an outflow needle), physical therapy, and acupuncture. Less commonly used methods include ultrasound, low-level lasers, and transcutaneous electrical neuromuscular stimulation (TENS).

Although there are thousand papers in the literature concerning TMJ Disorders, the effectiveness of the various treatments for TMD relief in general have been poor, inconsistent, or not well established. Therefore, it is not surprising that none of the numerous methods currently being used have come to be generally accepted as the treatment of choice for TMJ disorders.

Fortunately, most patients with TMJ disorders improve and obtain relief with or without treatment and conservative therapies should be encouraged before invasive treatments are considered.

As discussed previously in the tmj pain article, there is a direct connection between the tmj muscles, neck muscles and posture. The neck exercises from the menu at the top, left of the page are highly recommended along with posture recommendations. If you have had a whiplash injury or have neck problems, a chiropractic evaluation may be helpful.

A recent article in the Journal of Oral Rehabilitation, 2010 May 27. The association between neck disability and jaw disability, confirms a "strong relationship between neck disability and jaw disability" further indicating that "treatment needs to focus on both areas because the improvement of one could have an influence on the other."

Trigger points are known to become aggravated from muscle use, poor sleep, psychological tension and emotional stress, and their severity can fluctuate as the contributing factors change. Treating muscles with stretching, massage or deep pressure therapy to the neck and jaw muscles may provide relief.

Recently, the Journal of Manipulative and Physiological Therapeutics. Volume 33, Issue 1, Pages 42-47 (January 2010) did a study and found that stretching of the hamstring muscles (back of thigh), either one side or both, has an immediate relief effect over the masseter jaw muscle and the upper trapezius muscle in healthy subjects. In addition, an increase in maximum active mouth opening was also found after the stretching of the hamstring musculature.

Pharmacologic interventions similar to those for other musculoskeletal disorders are a treatment option. Acetaminophen and nonsteroidal anti-inflammatory drugs can help with acute and chronic pain. For muscle spasm and chronic bruxism, muscle relaxants or benzodiazepines may be necessary if conservative relaxation techniques fail. Tricyclic antidepressants may provide relief from pain, including pain from nighttime bruxism. Antidepressants that are used in the treatment of chronic pain syndromes might also be beneficial in the treatment of chronic TMJ disorders. However, care should be used when prescribed selective serotonin reuptake inhibitors because there have been rare case reports of selective serotonin reuptake inhibitor-induced bruxism.

Intra-articular injections of the TMJ with local anesthetics or corticosteroids can be used for the treatment of inflammation within the TMJ joint capsule. Intra-articular injection should only be used for severe acute episodes or after conservative therapies have been unsuccessful in obtaining relief. Repeated intra-articular corticosteroid injections are not recommended. A systematic review found insufficient evidence to encourage the use of intra-articular hyaluronate for the treatment of TMJ pathology. Local anesthetics and botulinum toxin (Botox) have be used in myofascial trigger-point injections for the treatment of chronic bruxism.

Dental occlusal splinting and permanent occlusal adjustment have been the mainstays of TMJ disorder treatment for years, although there is no clear evidence that malocclusion of the upper and lower teeth causes TMJ pain. Two main types of splinting are available: occluding and nonoccluding. Occluding splints, also called stabilization splints, are specially fabricated to improve the alignment of the upper and lower teeth. Nonoccluding splints, also called simple splints, primarily open the jaw, release muscle tension, and prevent teeth clenching. Occluding splints need to be fabricated and adjusted by a trained dentist and may cost several hundred dollars in overall treatment costs. Nonoccluding splints are typically made of a soft vinyl and are easier and cheaper to fabricate. Inexpensive versions can usually be purchased at local pharmacies. Permanent occlusal adjustment can be obtained through orthodontics or by grinding down the superficial tooth enamel to improve occlusion.

The Cochrane Collaboration recently reviewed permanent occlusal adjustment and occluding splint therapy for treatment of TMJ disorders. There was insufficient evidence to show benefit or harm with either treatment. Also, several trials comparing occluding and nonoccluding splint therapy have shown no significant differences in long-term treatment outcomes. Occlusal adjustment, either permanent or temporary, can still be an appropriate treatment for dental pathology, but its role in the primary treatment of TMJ disorders is uncertain.

Acute anterior displacement of the joint disc is a rare condition that causes the jaw to lock in the open position. This can lead to painful inflammation in the articular capsule and can inhibit swallowing and eating. Most patients with acute locking of the jaw have a history of episodic locking, a noticeable click with chewing, or a habit of teeth clenching. Disk displacement should be reduced as soon as possible. If the patient is unable to reduce the displacement by laterally (side) moving the mandible and opening the mouth wide, manual reduction by a professional may be attempted. Manual reduction of the disk can usually be achieved by inserting the thumb into the patient's mouth, grasping under the chin, and simultaneously pushing down on the posterior teeth and pulling up on the chin. The mandibular condyle will be distracted downward, allowing the disk to move posteriorly into place. The patient's head is stabilized, either by the examiner's opposite hand or a headrest or wall. A local anesthetic or intravenous benzodiazepine may be used to decrease pain and relax severe spasm before manual reduction. If the reduction is not successful, the patient should be evaluated by an oral surgeon as soon as possible.

Here are some simple things to keep in mind for tmj pain relief:

• Eat soft foods and stay away from chewy foods (for example, taffy)
• Try to use both sides of your mouth to chew
• Don't chew gum
• Don't open your mouth wide (for example, during yawning)
• Don't bite your cheeks or fingernails
• Take measures to reduce stress
• Apply a warm, damp washcloth or moist hot pack to the joint
• Relax the joint: let your mouth open and feel the weight of your jaw bone. Close your lips, but not tightly and place your tongue on the soft part of your upper palate (roof of mouth).

When your pain is better, you can do some exercises to make your muscles stronger to try and keep the pain from coming back. These exercises should not be painful. If it hurts to do these exercises, stop doing them and consult your doctor.

• Resisted mouth opening: Place your thumb or two fingers under your chin and open your mouth slowly, pushing up lightly on your chin with your thumb. Hold for three to six seconds. Close your mouth slowly.
• Resisted mouth closing: Place your thumbs under your chin and your two index fingers on the ridge between your mouth and the bottom of your chin. Push down lightly on your chin as you close your mouth.
• Tongue up: Slowly open and close your mouth while keeping the tongue touching the roof of the mouth.
• Side-to-side jaw movement: Place an object about one fourth of an inch thick (for example, two tongue depressors) between your front teeth. Slowly move your jaw from side to side. Increase the thickness of the object as the exercise becomes easier.
• Forward jaw movement: Place an object about one fourth of an inch thick between your front teeth and move the bottom jaw forward so that the bottom teeth are in front of the top teeth. Increase the thickness of the object as the exercise becomes easier.

Personal experience: When I was young, I had a bike accident where I was thrown from the bike and landed on my chin. A white t-shirt turned red with blood, eight stitches and some years later, in my teens, I began to experience tmj pain. It became quite bothersome and I consulted a dentist. The dentist examined me and determined I needed my bite reconstructed. Well, hours of drilling to reshape my bite over a period of weeks and under medication, the result was no relief! In frustration, I gave up and even threw away my bite plate. Some years later, I visited a chiropractor and after my first adjustment, I noticed something was happening with my tmj. Within the first week of adjustments, I noticed a definite relief of my tmj problem. The chiropractor said I would probably need to have my bite re-reconstructed after my neck was finished it's adjustments. No, I didn't go back to the dentist and yes, I still suffer from tmj problems, however, the chiropractic adjustments made it much easier to deal with and provided much needed relief from my tmj pain.

In a recent update by the American Association of Dental Research, they state, It is strongly recommended that, unless there are specific and justifiable indications to the contrary, treatment of TMJ patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities. Studies of the natural history of many TMJ problems suggest that they tend to improve or resolve over time. While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes, they present much less risk of producing harm. Professional treatment should be augmented with a home care program, in which patients are taught about their disorder and how to manage their symptoms.