TMJ is just anatomy. TMD is an umbrella term that involves orthopedic, muscular, neurological, rheumatological and/or dentally related issues.

​Clenching and grinding one’s teeth is essentially mother nature’s way of “catching our bite up” to the status and biomechanical position of our right and left TMJs. 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. Many times, too much opposing back teeth contact, in time, stimulates the 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 the function. The key: begin by objectively evaluating the orthopedic temporomandibular joint condition, and the condition, position, and degree of herniation (or lack thereof) of the cartilagenous discs.

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. TMJ imaging with CBCT and MRI is essential to properly diagnose the cause of clicking and popping.  Other digital metrics such as jaw tracking and joint vibration technology are good screening tools as well, but nothing beats the TMJ MRI.

Recent research has elucidated the relationship between cold sensitivity and the human bite (or occlusion). A phenomenon known as Frictional Dental Hypersensitivity (FDH) is often the etiology of confounding dental hypersensitivity when other organic causes have been eliminated.  The FDH theory therorizes that excessively flexed teeth from excursive occlusal contacts can result in hyperactive chewing muslces, lowering the threshold whereby cold stimulation is perceived by the nervous system. Applying occlusal therapy guided via objective occlusal metrics linked to electromyography readings of the muscles of mastication can lead to resolution of confounding cold hypersensitivities when all other potential etiologies have been eliminated.  Many times, confoundingly sensitive teeth are due to either dental work or orthodontic movements that have the opposing top and bottom back teeth contacting​ too long in the sideways, or excursive movements, in time. Autonomic sympathetic fiber hyperactivation is also believed to be connected to this tooth cold allodynia phenomenon.

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 no afflicted patient typically has received an objective and definitive answer, unless they have been exposed to a doctor who has been through the CNO curriculum of course!

Muscle spasm and fibrosis can result from many things, but often the tension results from either displaced TMJ 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. Ramped-up sympathetic tone or damaged cervical sensory nerves feeding the head can also be causative.

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?

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.

Chronic pain, no hope, chronic anxiety. Simple.

​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 TMJs, teeth, and/or temples.

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 TMJs as taught in CNO3.

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

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 TMJs and in your cervical spine. These cervical and TMJ issues may manifest as “TMD”.​ Proper 3D imaging of both the c-spine and both TMJs via CBCT and MRI are indicated to identify issues.

Think of top and bottom teeth as sensors that are connected to your nervous system and brain. These sensors communicate where your mandible/lower jaw is in space time. When the teeth don’t hit and interact with other opposing teeth (sensors) properly, there can be muscular dysfunction issues that may manifest as pain resultant of the muscles not being perfectly aligned biomechanically and neurologically, in space and time. Digital occlusal metrics can find tiny variations in the dynamic bite that matter, but firstly, one should vet the orthopedic TMJs to ensure that stable joints do indeed exist before chasing bite improvement. After all, who wants a tentative solution rather than a permanent solution?,.

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.

Displaced cartilage is fairly common, and when that protective layer is missing, jaw bone may repeatedly rub on skull bone, with resultant potential arthritic breakdown. As the jawbone breaks down, that too can change the bite and cause pain in and around the TMJs.

Excessive inflammatory fluid buildup in the TMJ mandibular bony condylar head is defined as an edema. Edema can only be seen on TMJ MRI’s and are a sign of active joint breakdown.Effusions are inflammatory buildups within the soft tissues in and around the TMJs. Though less serious than an edema, effusions can adversely affect both orofacial and dental health as well. 

When the jaw bone is of abnormal size or shape, this can alter the entire stomatognathic (chewing) system. The body will often adapt and remodel to this change over passing time. How it adapts can dictate whether or not things are stable and adapted orthopedically. Osteochondral growth defects are bony problems resultant of structural damage to the growth centers that are the orthopedic TMJs before full growth and development has had a chance to occur; typically before puberty.

The sympathetic branch of the autonomic nervous system is basically the body’s “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.

Braces or aligners can take months to 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 TMJs) 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.

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 occlusal therapy, provided that their TMJs have been shown objectively to be relatively stable and adapted per 3D MRI and CBCT imaging.

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

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

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

Chiropractic treatments typically give only temporary relief for TMD.  C-spine issues are almost universally part of the TMD patients problems however, so a chiropractor that specializes in upper c-spine is often on the treatment plan for a TMD patient.

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

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.

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

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.