About TMD

Symptoms
Causes
Current Treatments

Common Signs and Symptoms

Headaches

When muscles are overworked, they can become ischemic and painful. The neurology of the human stomatognathic (chewing) system is such that the more opposing back teeth engage one another as we move the lower jaw (mandible) around, in time, the more our nervous system reacts by pushing harder on the chewing muscles. Additionally, the status of the TMJ’s themselves can readily alter the human bite, once again causing excessive back tooth contact. So, “head” aches; the head contains muscle groups relating to chewing of course. What if you overworked those muscles, unknowingly, and what if almost no health practitioner knew that this timing relationship can be causative for your non-specific headaches?

Grinding/Clenching

​Clenching and grinding ones teeth is essentially mother natures way of “catching our bite up” to the status and biomechanical position of our right and left TMJ’s. Neurologically, our nervous system “dials in our bite” to match up to the TMJ hinges, basing how much alteration should happen upon the neurology that is definitively linked to muscular hyperfunction; the DTR theory. Too much opposing back teeth contact, in time, stimulates nervous system to push, tip, intrude, grind or possibly intrude teeth into bone, until such time as the front teeth do their job of separating the back teeth apart during function.

Clicking/Popping

​Cartilage normally sits atop the mandibular condylar head, that part of the lower jaw bone that inserts into the skull base, just in front of our ears. The cartilage is attached to the condylar head with ligaments, and the cartilage has a muscle, called the lateral pterygoid muscle, inserted into it. When the cartilagenous ligaments get stretched or torn, the physical displacement of the cartilage coupled with the tension that may be imparted to cartilage from the lateral pterygoid muscle, may readily cause a click or pop to be heard or felt as the cartilage is snapped between the condylar head and the skull base. This clicking and popping is a sign that the cartilagenous ligaments are loose, and that the cartilage is displaced. Sadly, clicking and popping is common and typical since many people have torn or stretched ligaments. Silencing of clicking and popping is not necessarily a good sign, since it implies that the cartilage is even further displaced forwards over time, subjecting the bony condylar head to even less protection from mechanically rubbing against the lower skull base bone.

Tooth Sensitivity

Recent research has elucidated the relationship between cold sensitivity and muscular TMD issues. A phenomenon known as Frictional Dental Hypersensitivity (FDH) is thought to be responsible, in that excessively flexed teeth due to hyperactive muscles of chewing, lowers the threshold whereby cold stimulation is perceived by the nervous system. Applying DTR therapy to a patient with hyperactive chewing muscles, almost universally reduces their cold sensitivity perception. Bottom line, sensitive teeth are typically due to either dental work or orthodontic movements that have the opposing top and bottom back teeth contacting​ too long in sideways movements, in time. This is typically curable by applying DTR therapy, regardless of the level of exposed dentin or cementum (in contrast to the 1964 Hydrodynamic theory of Branstrom and Anstrom). The CNO coursework introduces doctors to the FDH concepts.

Depression

​Deprive a chronic pain patient of hope in regards to what is wrong with them and naturally that patient will become depressed over time. Subjective and empirical diagnoses and treatments that fail TMD patients leads to depression, because nobody typically has an objective and definitive answer, unless they have been exposed to the CNO curriculum of course!

Anxiety

​Chronic pain, no hope, chronic anxiety. Simple.

Muscle Tension

​Muscle spasm and fibrosis can readily result from either displaced cartilage and/or opposing back teeth engaging one another for too long, in time. Chronic muscular tension of the chewing muscles may result which are often times painful, as well as accessory muscles of mastication (chewing) that are present in and around the neck.

Neck Tension

​Several muscles in the neck are accessory muscles of mastication. These muscle groups are often recruited to assist chewing muscles that are overworked and spent, resulting in chronic neck tension. Additionally of course, cervical spine damage can directly cause neck tension as well, and it is relatively common for a patient with damaged TMJ cartilage to also have damaged cervical cartilage. The trick is delineating which source is primarily responsible for the neck tension, or is it both?

 
Shoulder Tension

Accessory masticatory muscles such as the trapezius and platysma muscles may also become overworked and spent due to overworked chewing muscles leading to shoulder tension at times.

Common Causes

Unmeasured Dental Work

Most Dentists are unaware of how their work on your teeth can affect your chewing muscles. For instance, a crown(s) or filling(s) can change the bite and cause problems resulting in common TMJ symptoms, simply by the bite being “high” or the tooth anatomy is the wrong shape. This inaccuracy is directly connected to the fact that research shows that dentists can only choose the proper contact 12% of the time when they only using traditional bite ribbon. This means that they are going to choose INCORRECT tooth contacts to address a patients bite issues 88% of the time! There are studies that have statistically demonstrated this! Unmeasured tooth alignment can readily cause headaches, tooth hot and cold sensitivity, grinding, stiff neck and shoulder muscles, and other “TMJ” issues. The key lies in diagnosis (or multiple diagnoses, or layers), proving objectively (whenever possible) that your temporomandibular joints and surrounding structures are both stable. IF SO, then these issues are likely happening because your bite is misaligned and muscular spasms are causing your tempormandibular dysfunction. IF NOT, then your issues may also have other layers that are causing your problems. Again, “TMJ`’ is typically NOT a psychological problem; it is literally in your head, NOT your mind! Teeth, muscles, bone, joints and cartilage; we methodically measure all of these co-factors to arrive at a working, and ultimately, a definitive diagnosis.

 
Damaged Cartilage

​In perfect TMJ health, cartilage sits on top of where the lower jawbone articulates into your skull base in front of your ears. That cartilage has a thickness. There are ligaments holding that cartilage there, just like there are ligaments holding the cartilage in place between the long bones of your leg. Tear or stretch the ligaments, and the cartilage will likely displace forwards in the TMJ. When the cartilage is forwards, many times this will change the bite, with back teeth typically hitting harder than they should. When back teeth hit too hard, your nervous system does not like this and responds by making the chewing muscles work harder and harder, not allowing those muscles to take a break. This can readily lead to chronic pain due to the muscles being overworked. Bottom line, damaged cartilage is another pathway by which your bite may change, potentially leading to chronic pain around your TMJ’s, teeth, and/or temples.

Dead Bone

If the blood supply to your mandibular condyle is cut off, then the jaw bone can die. This is known as Avascular Necrosis (AVN). AVN can happen for several reasons, but perhaps the most common is due to the cartilage ligaments being torn and the anteriorly displaced TMJ cartilage pinching off the blood supply to the condyle. This may happen in particular if the cartilagenous disk is displaced forwards and medially. AVN is fairly rare, but needs to be identified. The only non-invasive way to properly identify AVN is via proper MRI imaging of the TMJ’s.

Head Trauma (recent or old)

Physical trauma can tear ligaments, both in your TMJ’s and in your cervical spine. This can cause TMD issues from both the TMJ’s and the cervical regions.

Whiplash

A whiplash is a rapid, acute injury to the head that can once again tear or stretch the ligaments in one or both of your TMJ’s and in your cervical spine. These cervical and TMJ issues may manifest as “TMD”.​

Improper Bite

Think of top and bottom teeth as parts of a machine. When they don’t hit and interact properly, there can be muscular issues that may manifest as pain resultant of the muscles not being perfectly aligned biomechanically and neurologically, in time.

Jaw Dislocation or Injury

Dislocations and injuries damage cartilage, which can lead to inflammatory and degenerative changes of the bone, both of which can readily alter the bite and lead to chronic pain conditions.

Arthritis

Displaced cartilage is fairly common, and when that protective layer is missing, jaw bone rubs on skull bone, with ensuing arthritic breakdown. As the jawbone breaks down, that too can change the bite and cause pain in and around the TMJ’s.

Erosion of the Joint

Excessive inflammatory fluid buildup in the TMJ mandibular condylar head is defined as an erosion. Erosions can only be seen on TMJ MRI’s and are a sign of active joint breakdown.

Structural Jaw Issues

When the jaw bone is of abnormal size or shape, this can alter the entire stomatognathic (chewing) system. The body will adapt and remodel to this change over time. How it adapts dictates whether or not things are stable and adapted.

Cervical Neck Damage

​Cervical issues readily contribute to TMD pain issues. The neck should always be considered as a potential player in the TMD patient.

Sympathetic Input

The sympathetic branch of the autonomic nervous system is basically the bodies “fight or flight” mechanism. Of significance, sympathetics cause vasoconstriction (shrinking) of blood vessels​. Chronic vasoconstriction starves muscle cells of oxygen, leading to ischemia and pain. Excessive sympathetic stimulation in the head and neck can readily create chronic pain for patients. Excessive contact between opposing teeth, over time in the functional movements, can overstimulate the sympathetic nerves in and around the teeth leading to chronic pain.

 

Current Treatments Only Targeting Symptoms

Here is a list of Treatments that targets only the Symptoms
SPLINT THERAPY

Splints may indeed protect the teeth, but technically may cause more problems within the joints themselves. Imaging the cartilage and bone within the joints should ideally occur prior to deciding on splint therapy or orthotic construction relative to bite position and splint design. Splints universally remove the patients’ ability to adapt their teeth to the status of their TMJ’s as teeth individually adapt to muscular changes, over time, to self-resolve TMD issues.

 
ORTHODONTICS / BRACES

Braces take years to move teeth, and many cases of TMD do not respond after orthodontic therapy since the actual cause of the TMD may have been joint based and never properly diagnosed. Additonally, if orthodontic movements (on a patient with initially perfectly normal set of TMJ’s) are left unmeasured in relation to timing and force between opposing teeth, orthodontics can actually cause painful muscular TMD issues relating to not only hyperactive muscles of mastication, but also to orthopedic issues involving the lateral pole of the cartilagenous disk.

 
Sympathetic Input

The sympathetic branch of the autonomic nervous system is basically the bodies “fight or flight” mechanism. Of significance, sympathetics cause vasoconstriction (shrinking) of blood vessels​. Chronic vasoconstriction starves muscle cells of oxygen, leading to ischemia and pain. Excessive sympathetic stimulation in the head and neck can readily create chronic pain for patients. Excessive contact between opposing teeth, over time in the functional movements, can overstimulate the sympathetic nerves in and around the teeth leading to chronic pain.

 
BOTOX INJECTIONS

Injecting Botox into muscles biochemically “relaxes” them, but only for several months. If the patients finds that they had great relief with Botox but their symptoms returned, they are likely a great candidate for DTR therapy, after the other tools used by the CNO have objectively confirmed that other issues do not exist.

 
MUSCLE RELAXANTS

If a patient reacts positively (but temporarily) to muscle relaxers, that is a good sign that a CNO doctor can help, as this implies that the masticatory/chewing muscles are overworking. If it is the bite causing this (which it often is due to orthodontic or dental work that is placed unmeasured), DTR therapy would likely help the patient.

 
MASSAGE

Treating the muscles throughout the head and neck to break up trigger points only gives the TMD patient temporary relief.

 
DIET

Are you avoiding chewing gum, tougher foods, and cold foods and drinks? These are signs of a potential TMD issue…

 
TRIGGER POINT INJECTIONS

Injecting anesthetics into muscle does not address the core reasons for a muscular TMD issue.

CHIROPRACTOR / OSTEOPATHY

Chiropractic treatments typically give only temporary relief for TMD.

DRUGS or PAIN TABLETS

Ibuprofen, Naproven, Anti -Inflammatories, narcotics, anxiolytics: find the root cause of your problem and get off of the meds!

PSYCHOTHERAPY

Have you been told that your “TMJ” is all in your head? They are right, but they are wrong. The joints, muscles, nerves, teeth, cartilage, bones and ligaments that contribute to TMD issues are just that, in your head.

TENS THERAPY

Transcutaneous Electrical Nerve Stimulation: temporarily relaxes the muscles, period.

 
REDUCING STRESS

Your emotional well-being or problems at school or work have little to do with your TMD condition. Stress as it relates to TMD is physical, biomechanical, infectious, hormonal, or biochemical in nature.

 
CNO FOUNDER
BOARD OF ADVISORS
ABOUT CNO CONTINUING DENTAL EDUCATION
The CNO purpose is to train dental professionals in TMD and occlusal diagnosis, 3D TMJ MRI and CBCT Imaging, and occlusal science so that they can in turn provide hope and direction for many patients with bite (occlusal) and TMD issues.

Disclaimer: The CNO makes no representation as to the quality or scope of a member's medical or dental practice, or as to how closely the member adheres to the principles and practices taught by the CNO. A patient must use their own best judgement after careful discussion with their health care practitioner about the care that will be provided. When using this directory, I understand that it may not be used as a resource for verifying the licensure or credentials of a listed healthcare provider. The CNO makes no attempt to verify the licensure or credentials of its members.

*The American Dental Association does not recognize a specialty in “TMJ”, and as such, there is no specialized training required to perform or advertise such services.
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