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- The TMJ (Temporomandibular Joint) is the joint that connects the lower jaw to the skull. It is found just in front of your ear.
- The joint has a small cushioning disc between the two bones. This disc allows sideways and forward movement and when damaged or displaced it can be an important factor in the pain process.
- Pain and functional issues linked to the TMJ and its associated muscles are referred to as TMD (Temporomandibular disorders).
- If the muscles spasm, you can be left with your jaw locked in an open or closed position. This can be particularly disconcerting and painful.
- If you suspect TMD related pain, please contact us immediately. The more you wait, the more difficult it can be to relieve the pain or relax a lock.
What are the signs and symptoms of TMD?
TMD can be difficult to diagnose as it can present with a wide range of signs and symptoms. One or many of the items listed below may be present:
Effects on associated muscles.
The most common symptoms are related to the surrounding muscles.
- Headache and facial pain.
Often it’s one sided and in the area of the temple or near the cheeks.
Pain may occur particularly on or after chewing, or first thing in the morning.
- Neck or shoulder pain.
Pain from the jaw muscles may spread (via shared nerves) to nearby head and neck muscles.
- Difficulty in opening or closing your mouth
- Middle ear effects.
Ear pain or ringing in the ears can occur. A feeling of blocked ears and dizziness is also possible.
- Sinus and eye pain.
Pain in the area of your sinuses or behind your eyes can be related to referred pain from jaw muscles.
- Bite change.
Different rates of spasming of surrounding muscles can temporarily change in the way your teeth come together.
Effects on the joint itself.
- The pain within the joint
This is often muscular pain related to trauma to the small muscles directly behind the disc. Due to its physical proximity to the ear, this can at times be felt as ear pain.
- Popping, clicking or grating sounds
Sounds can come from the joint when the jaw moves.
Not all clicks are a problem – many will resolve naturally over time.
As soon as clicks are associated with pain or locks, they need closer assessment.
- Opened or closed locks.
If the disc becomes misshapen over time, or finds itself consistently out of position, it can become wedged between the two bones causing a lock.
Heavier than normal biting forces will lead to teeth wear and consistent chipping or breaking of teeth.
Grinding can be noisy enough at night to disturb sleep partners.
What are the factors involved with TMD?
TMD is made up of a complex family of conditions and is influenced by environment, genes, behaviour and sex.
Many TMD patients also suffer a variety of other painful conditions that affect other areas of the body but their exact links are unclear. The most common of these are fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, rheumatoid arthritis, chronic headaches, depression, and sleep disturbances.
It’s becoming increasingly obvious, as we further understand the complexity of TMD, that further research involving many medical disciplines will be needed to completely unravel its secrets.
The following issues can contribute to TMD:
Long term grinding (forcibly sliding your teeth over each other) and clenching (tightly clamping your teeth together) causes repeated episodes of trauma to the joint, teeth and associated muscles.
It’s not just the large forces generated, but their duration and frequency together that are so damaging.
Very often the habit is unrecognised as it may be a subconscious habit during the day, and noise is not always produced to be heard while asleep.
People who regularly brux their teeth may be able to generate 3 times the amount of force than people who don’t grind.
Other related habits such as thumb sucking, abnormal tongue posture habits and biting on pencils or nails can also cause TMD.
Bruxism is somehow related to stress. The exact relationship is not known, but it is not a direct cause and effect relationship.
Different forms of stress can trigger bruxism in a person who is already genetically predisposed to it.
We often see a painful tooth acting as a trigger to a grinding or clenching episode. Teeth pain along with TMD pain is a common result.
The struggle to breathe while snoring or sleep apnoea may trigger a reflex action to grind. The jaw movement could be the body’s attempt to open the airways.
Life’s anxieties or sleep depravation often lead to an increase in grinding. TMD in these cases are often cyclical in nature
Sleep disorders such as snoring and sleep apnoea.
- Sleep may play a role in this process, so any signs of poor sleep should be further investigated.
- The association is not totally clear but some recent research suggests grinding may be a reflex action to help trigger opening of airways which are occluded in these conditions
- Poor sleep and sleep posture may also aggravate TMD problems.
- Interestingly, people tend to brux more when they sleep on their backs. Sleep apnoea is also worse in this position.
Neck / back problems
- The chewing muscles are in balance with the muscles in the back and the front of the neck.
- If these neck muscles are not functioning correctly, this balance will be effected and the jaw muscles may develop pain while trying to compensate for the change.
An accident involving the jaw such as a fall, a car accident, or a punch to the jaw could break the jaw bone or damage the disc within the TMJ. Conditions that could arise from this are:
- Damage to the joint is usually found on one side only.
- Unlike rheumatoid arthritis, it can be the first joint in the body to be affected.
- It can be painful from the moment damage begins, or be quiet until triggered at a later date.
- It most commonly effects middle aged females.
- Various symptoms are seen including:
- pain with opening,
- difficulty moving the jaw to the side with the healthy joint
- a coarse grinding noise on chewing
- a history of a click that has disappeared
- movement of the whole jaw to the side of the damaged joint on opening.
- Inflammation associated with Rheumatoid arthritis eventually deforms joints by destroying cartilage and eroding bone.
- It’s very rare for the TMJ to be effected in the early stages of the disease making it difficult to diagnose if symptoms aren’t present elsewhere.
Treatment for TMD
Although a special joint, the TMJ has much in common with any other joint in the body and therefore its problems and solutions are similar. Most people can be spared the expensive and invasive treatments of the past.
Modern treatment for TMD is far more conservative than in the past. Most treatment is aimed at relieving the symptoms and preventing future damage.
Conservative management could progress as follows:
A visit to your doctor would be a good start. They could rule out any other medical conditions that could cause head and face pain.
Dental assessment and education
- After a comprehensive evaluation, we will discuss our findings, clarify the diagnosis, educate you about your condition and begin to put in place a treatment strategy.
- For many, the reduction in stress that comes with knowing what the issue is can begin to settle the pain.
- Often the person suffering from TMD is unaware of the triggers that have aggravated the pain. Becoming conscious of subconscious habits and putting a halt to them can make all the difference.
- Muscle pain or myalgia is the most common cause of jaw pain.
- A temporary change to a softer diet should reduce the stress on the jaw joint and associated muscles.
- Application of warm or cold compresses to the area around the jaw joints can be helpful.
- If the pain is suspected to be related to muscle spasm, mild anti-inflammatory and muscle relaxant drugs can be prescribed at the first visit.
- Occasionally medication can be provided to assist in sleeping.
- Gentle stretching of muscle fibres in spasm may provide healing and relief.
- Various jaw exercises can begin after initial pain relief to help retrain, stretch and relax the muscles.
- Muscle spasm may be reduced with physical therapy and massage.
- In some severe and unrelenting cases relaxation training and biofeedback, along with psychotherapy can be helpful.
- Adjust the bite of a recently placed dental restoration – even a slightly large filling can cause a bite change leading to muscle spasm.
- A bite guard (Occlusal Splint) is custom made to fit over all teeth of your upper jaw.
- This U-shape device is made from a hard, wear resistant plastic that’s designed to separate the jaws.
- It is commonly worn during sleep.
- This separation can reduce muscular power by 70% during grinding, and will allow smooth movement while grinding which helps further relax the jaw joint and muscles.
- Some appliance designs provide a device that is placed over only the upper front 6 teeth. Such devices are undoubtedly easier to wear, but in 8% of cases the bite will be changed irreversibly. Also, the two front lower teeth can be severely worn or become quite tender. We do not place anterior splints for this reason.
- Recent research suggests that in some cases grinding could be a reflex reaction designed to open an airway that is closing during snoring or sleep apnoea.
- In such cases the use of a CPAP machine or a dental device to hold the lower jaw forward (Mandibular Advancement Splint) may reduce bruxism.
- In the past it was thought that the way teeth functioned against each other strongly effected TMD.
- Treatments such as “bite adjustment” or “bite equilibration” and orthodontics were prescribed to provide a more ideal bite.
- Today, researchers have found that the bite is not as important as once thought
Surgery on the jaw joint is difficult and has mixed results. As a result it is considered a treatment of last resort.
Both bite correction and Surgery once applied cannot easily be reversed. They should only be used after conservative reversible procedures have been exhausted and are unsuccessful.
If Major Trauma is involved…
- You will be unable to close your jaw. Your jaw needs to be carefully and gently manipulated until it moves back into the correct position.
- Supportive therapy as listed in the Pain Management section above will be needed.
- The broken parts need to be repositioned and then splinted to keep them still while healing.
- A fracture may involve either the jaw joint or the body of the jaw itself.
- A minor fracture may be immobilised by joining the upper and lower teeth together for several weeks. This is called “External fixation”.
- A more severe fracture can require a full surgical treatment and “Internal Fixation”.
- Both of these procedures are generally carried out under concious sedation, or full general anaethesia.
Further tests and referral
- We will commonly take an OPG (x-ray) radiograph as an initial screening of the temporomandibular joints to rule out arthritis or other bone irregularities.
- Many of the causes of TMD as listed above will require more sophisticated tests to ensure proper diagnosis and treatment such as:
- Head and neck examination
- blood tests
- Joint visualization through further x-rays, CBCT or MRI scans.
- Because there are different approaches to the management of TMD problems, not all of which are based on science, caution is advised when seeking professional help.
- The most qualified dental practitioners in this area are those who have completed postgraduate programs in Oral Medicine or Orofacial Pain. All difficult cases we meet in this practice are referred to one of our excellent Oral Medicine specialists.
- The “alignment” of teeth and jaws is no longer analyzed nor changed because these factors have been shown to be mostly irrelevant to what is causing the TMD symptoms.