What is TMJ or TMD and what are its symptoms?

The temporomandibular (TMJ) jaw joints in front of the ear are the hinges between the jawbone and head. Neck movement, breathing, talking, chewing, swallowing, smiling, all require jaw movement. As the lower jaw moves, it requires both TMJ's to move and slide freely. When there is an abnormality with the joints and associated muscles of the jaw, pain can develope. Symptoms of TMJ Disorders include the following:

• Clicking, popping joints/frank noise
• Headache, neck pain, face pain
• Chew pain, swallowing difficulty
• Ear Pain, blocked eustachian tubes
• Pain behind eye
• Locking, inability to open, dislocation
• Dizziness, tinnitus/ear ringing
• Muscle soreness in temple region, side of face, neck
• Awaking with sore clenched jaws
• Throat pain

Headache and orofacial pain are often complex, involving both local areas and other regions of the musculoskeletal system of the body. Thus, a thorough history and comprehensive clinical examination are done at the first visit. At chairside, clinical evaluation and charting involves the structures inside the mouth and outside. Palpation of the Temporomandibular joints, muscles of mastication, and entire head/ neck region is critical in assessing orofacial/TMJ related pain and headache.

Range of Motion of the jaw in all dimensions is measured, correlated to stethescopic sounds. The movement of opening and closing should be smooth without jarring or deflection. Lateral side to side and forward motion should be unstrained. When there is restriction and locking/popping of the joint, the existing closed position of the mandible and the fit of the teeth are manually compared to other potential jaw positions. This is done to test for differences in TMJ disk/joint function im-provement. Normal opening of 50 mm is seen here, without deviation to the side or joint noise.

Diagnostic procedures will be recommended such as impressions of the teeth/jaws, from which dental study models are made. Radiographic/X-Ray imaging is done to view jaw structures and abnormalities of the teeth,TMJ, head and neck region. A panoramic radiograph of the jaw is seen being taken here:

Panoramic Radiograph shows entire jaw-healthy structures-normal view seen in this photo:

A complete orthodontic/orthopedic facial skeletal analysis with anatomic tracings is used to help correlate teeth positions and jaw posture to boney growth. This is seen from the lateral skull, cephalometric x-ray view:

Besides palpation assessment, other procedures may involve measurement of muscle dysfunction and contraction/spasm via an EMG, or electromyogram, to the head, neck and jaw region. Tightness produces contraction and muscle referred pain.After a thorough diagnostic workup, and case assessment/plan discussion, a conservative course of treatment is usually recommended. This may typically involve an initial pharmacologic approach to acute pain and physical medicine modalities, such as moistheat/ hydrocollator pack , cold/vapocoolant spray & stretch, EGS electrogalvanic stimulation, TENS transcutaneous electrical stimulation and ultrasound.

The use of light wave monochromatic Infrared energy for wound healing has been well established over the past 40 years. Both visible and infrared light have been shown to effect at least 24 different positive changes at the cellular level. With absorption of therapeutic light waves, unique therapeutic effects in tissue occur via photobiochemical reactions. Indeed vision, photosynthesis, tanning, and vitamin D metabolism are responses to wave-length dependent light reactions. Increase of vascularity with new capillary formation, stimulation of collagen production for damaged tissue repair, release of ADP for cellular metabolism/energy, increase of lymphatic system activity, with increase of lymphatic vessel size and flow for edema/swelling reduction. Increases RNA and DNA synthesis, reduction of excitability of nerve tissue, pain relief, stimulation of fibroblastic activity to aid repair, increased phagocytosis in blood cell "cleanup"/ scavenging activity, critical in infection control. Thermal effect, without cellular heat from the diodes; stimulation of granulation and connective tissue for ulcer and wound healing, with acetylcholine release and parasympathetic effects.

There has been recent development for Orofacial region/TMJ pain , with new infrared treatment modality delivery. The applicability to the jaw/TMJ region and cervical is done through two hand pieces mounted inside the medical device, which looks like stereo headphones; this houses the multiple light emitting phototherapy/low energy laser diodes. Treatment of joints and deep muscle is approached directly, with each side is treated as a unit. With the headphone-like dual assembly infrared system, there is delivery of bilateral side-to-side therapy.

Manipulation/mobilization procedures to jaw and neck region, trigger point injections, home care exercises and postural stress/tension reduction are also utilized to help with long-range stabilization. These are often integrated with an initial in-traoral daytime orthosis/ soft mouthguard and then a nightguard.

Splint Appliances: A hard laboratory processed splint is usually prescribed for longer term use, 24 hours a day in acute situations. The goal is to reduce pressure on the joint to get it to settle down (decompression).

**** Further more detailed information available through patient/consumer information catalogue****

A Full arch maxillary splint appliance is seen here, with functional overlay occlusion/bite for chewing. Biting surfaces help guide jaw downward and forward to reduce and reposture disk of TMJ. Anterior coverage is clear for daytime esthetics. Same principles of design for mandibular splint apply. For night time only, a "pull forward ramp" may be added, with breathing holes. Arch bar and clasping provide for additional retention; a flat-planed design for primary muscle/clenching type pain may be elected. Return visits require further bite/appliance adjustments, coupled with therapy. Long-range plans may call for other dental rehabilitation, orthodontic, and prosthodontic considerations.

Referral may be made for an MRI or magnetic resonance image of the joint, where potential surgery is anticipated for dislocation or chronic displacement. Maintenance/return visits with continued therapy and splint/niteguard use help prevent relapses.

Mintiva TMJ is a new topical treatment for TMJ pain, featuring a proprietary deliver system that absorbs quickly, effectively relieves pain, and allows greater range of motion of the jaw. TMintiva is an over -the- counter topical cream, developed to dental professionals' specifications to target and relieve temporomandibular joint pain. It is non-greasy, fast acting, and does not leave a medicinal smell like some topical treatments.Other Mintiva formulations can also relieve arthritic neck and back joint pain. The cream is applied to the TMJ, jaw muscles, massaged into the skin. For further information and ordering, click on the following link, using coupon discount code #1003: www.mintiva.com.

Obstructive Sleep Apnea (OSA) is a serious respiratory disorder affecting a significant portion of the population. Estimates run from 9% to 40% of the male population between the ages of 40 and 60 and 4% to 25% of the Female population in the same age group. Sleep apnea (OSA) is defined as a cessation of all nasal and oralbreathing, despite diaphragm activity, for periods of ten seconds or longer; "central" apnea is cessation of breathing with no diaphragm activity, vs. "mixed", a combination of both. A significant concern about a potentialsleep apnea problem is suggested from the following symptoms:

• Snoring
• Daytime Sleepiness
• Awakening Headache
• Clench/grinding teeth at night
• TMJ Soreness on awakening/clicking
• Fatigue
• Restless Sleep with arousals, fragmented sleep, awakening with gasping
• Anxiety with breathlessness
• Overweight

With these presenting symptoms, referral for a Sleep study/polysomnography may be justified after clinical evaluation by the Dentist/Physician. The definitive diagnosis of this disorder is done through sleep laboratory studies with an overnight Sleep Polysomnography. Sleep polysomnography features electrocardiography/EKG, brainwave electroencephalography/ EEG measurements, motor activity extremity measurements, diaphragmatic/chest movement, eye movement, pulse oximetry for oxygen desaturation measurement, and inhalational/exhalational oro-nasal flow characteristics. Complications from Sleep Apnea include: falling asleep while driving a motor vehicle, cardiac arrythmia, increased cerebrovascular accidents, high blood pressure, and complete cessation of breathing from occlusion of the airway.

Symptoms related to Sleep Apnea (obstructive sleep apnnea /OSA) include the following: Loud snoring, witnessed apnea events, daytime sleepiness/narcolepsy, disturbed sleep, daytime irritability, poor memory, morning headaches, decreased cognative functions, nocturea/ night- time awakening arousals, extreme anxiety, and fatique.

One of the cardinal signs on patient evaluation and questioning includes the presence of snoring. While snoring itself may be a noxious habit affecting family/those around the snorer, snoring in and of itself may not be a major health hazard. The problem exists however, that there is a high correlation between snoring and obstructive sleep apnea symptomatology and its progressive developement into obstructive sleep apnea patterns. The standard protocol for diagnosis has been referral with the patients'physician and a sleep laboratory polysomnography study.

There has been a significant increase in interest within the medical community of dentistry's potential role in aiding patients with mild to moderate obstructive sleep apnea. The July 1995 publication of the American Sleep Disorders Society of their protocol for treatment of sleep apnea has been a major step forward in dental therapy of this major health problem The use of oral repositioning appliances has become an accepted part of conservative treatment of such patients.

Other considerations for treatment of sleep apnea include: CPAP- Continuous Positive Airway pressure, and surgical approaches to soft tissue/oropharynx modification. Surgical techniques have involved mandibular advancement, tonque resection, tonsillar and adenoid tissue removal, nasal obstruction surgery, deviated septal modification, nasal polyp removal and UPPP(uvulopalatopharyngoplasty) and more recently, LAUP- Laser -assisted uvulopalatal-plasty. Any one of these procedures or a combination of them may be applicable to each patient on an individual basis. Proper assessment of such patients is essential, who may have complicated medical histories. Medical factors need to be considered which include: emergency status of patients'respiratory system; trachestomy has been done in the past for acute obstruction. Obesity of patient is a significant factor and weight control has been done as an initial conservative step. Proper medical/dental team management is essential!

The use of jaw repositioning appliances has been in the dental literature since the early 1980's and an increasing awareness by the dental profession has been evident with the growth of the International Snoring Association and the Sleep Disorders Dental Society. A wide assortment of designs of intraoral orthotic repositioning appliances have published, and are being taught at postgraduate courses. The efficacy in design of these appliances is based on ability to position the jaw, bring the tonque forward and open up the occluded airway or narrowed airway space. Measurement of changes with and without the appliance have been discussed from lateral skull/ cephalometric measurement techniques, CAT Scan and M.R.I., magnetic resonance imaging techniques. Most recently , the use of magnetic resonance imaging/ M.R.I. software for airway views with and without the appliance, can establish a baseline and a potential increase in the patients' airway opening/volume. Lateral airway view of MRI is seen in film:

    

The most-likely obstructed areas in snoring and sleep apnea are the 3 divisions of the upper airway and throat: the oropharynx, nasopharynx and hypopharynx. The areas that particularly relate to jaw repositioning are the nasopharynx and hypopharynx. The documentation of dimensional changes in the airway structures by 3- D M.R.I. computerized analysis, including cone beam I-CAT technology imaging of the airway.

Diagnosis: Level of severity will be indicated from such a study, with recommendations . The findings may indicate no snoring, mild to moderate obstructive sleep apnea, or severe apnea with cessation of breathing of critical significance.

Treatment of choice may be weight loss, medication, Respiratory nasal CPAP (continuous positive airway pressure) device worn all night, ENT/ palatal surgery, or dental jaw repositioning appliances worn intraorally. The choice of therapy would depend upon the objective findings of the sleep study, in addition to the patients' presenting complaints, physical examination, and Doctor's preferences.

If a jaw appliance is to be done, the affect of such repositioning on the airway is tested with a jaw positioning temporary device, such as this waxup bite form, shown interposed between upper and lower jaw plaster dental models. A temporary appliance may be made at this position.

  

This positions the jaw further down and forward, increasing the total volume/space in the mouth and base of the tongue. The patient is sent with this, for MRI scan, with and without the appliance in place.The purpose of the 3-D M.R.I. is to verify with objective findings, specific areas in the airway which do change and which areas are still restrictive, necessitating a team approach in the management of this type of potentially serious clinical case pattern.*

Design of the long-term appliance can then be done, correlated to sleep study findings. One such positioning device is seen in this photo, repositioning the jaw and opening up the airway. MRI measurements indicated a 32% total increase in airway breathing volume on this case in comparison to baseline.

  

A properly designed dental snoring / sleep apnea appliance can go far in rehabilitating the patient with sleep deprivation. One particular appliance design, the "Halstrom Hinge Appliance"TM, utilizes a custom fitted upper and lower splint with a titanium precision attachment. This allows the jaw to move slightly while the patient is in different sleeping positions, still keeping it forward to clear the airway. The system design (see photo) also provides posterior molar area pivoting to support the TMJ-Temporomandibular Joints.

Appliances / Oral Airway Dilator Designs:
All Snoring/Obstructive Sleep Apnea Intraoral Appliances are designed to advance the mandible and dilate the airway.

1.The Silencer® System: This appliance incorporates the Halstrom Hinge Titanium Precision Attachment at the incisor level, allowing sequential 2 mm advancements up to 8mm, lateral movement 6 mm, 3 mm bilaterally, and vertical pin height replacements. A flat posterior bite plane is provided for the biting surfaces.

Other adjustable intraoral appliances besides the Silencer® also allow lateral jaw movement and some vertical change, as well as a variable forward progressive movement. The following appliances, which have had extensive published clinical research include:

2.The OASYS TM Oral Nasal Airway System allows mandibular advancement with a combination upper and lower splint with locking orthodontic slide wire attachment. The system features nasal pads which engage the inner lip surfaces to improve airflow through the nose.
3.The TAP III-Thornton Adjustable Positioner®, which allows for progressive 1/10 mm advancements of the jaw via an anterior screw mechanism at the labial aspect of the upper splint.
4. The SommoMed MAS Mandibular Advancement Splint allows for opening and closing. Jaw advancement comes from a lateral in on the sides of the lower splint as it engages a moveable wedge of the upper. The upper screw-plate component can be sequentially moved in 1/10 mm increments as the jaw/airway is titrated. The appliance is very comfortable for patient adaptation.
5. The Homeoblock TM appliance system is used to expand the dental arch and level mis-aligned teeth. It is used in adult cases to widen the maxilla to provide more room for the tongue. With upper and lower dental arch expansion, the mandible can come forward, allowing more airway space in many cases. It can be a first stage of treatment via orthodontic intervention, for obstructive sleep apnea situations. The appliance is worn primarily at night only. The amount of expansion is 1/4 mm per week. It has been used to improve facial esthetic and growth.
With all patients with sleep apnea, titration/adjustment and follow-ups are needed. Evaluating the patient response and effectiveness of oral appliance involves subjective improvement (spouse assessment, Epworth Sleepiness Scale, comfort, compliance, symptom review). It also involves the use of objective overnight home monitoring such as pulse oximetry, and other sleep/nasal recording devises. Follow-up polysomnography referral with laboratory and sleep medicine specialist is part of the dentist/physician team approach protocol.

A sleep apnea dental anti-snoring device can be an equal benefit to one's sleeping partner, allowing two to sleep better by treating one! Extensive research* has gone into treating this disorder by clinicians familiar with its medical/dental benefits.

Many insurance plans will cover such appliances under the medical coverage benefit, where proper documentation of medical necessity has been established.

*For a detailed scientific paper on this subject refer to:
Atlas of Oral Surgery Clinics of North America, Vol. 15, #2,Sept. 2007:
Oral Appliances in the Treatment of Obstructive Sleep Apnea,
Elsevier-Saunders Publishers.