How best to treat TMJD ?

Often a splint or orthotic will be proposed

There is no real consensus as to how best to treat TMJD and there are many different approaches to best relieve pain in the jaw joints and surrounding structures and muscles . Dentists here discuss these different approaches as do patients . Often a splint or orthotic will be proposed . If you are having splint treatment do let us know how you are getting on …. Here is a link to a site that describes some of the more common splints on offer


Discussion


Curtis Westersund
Interesting Eva Willer-andersen. What I see when I look at the list of orthotics a lab can create for its clients is a bunch of people looking for an answer to the question “Why is this not working?”. Either that or a bunch of docs thinking “How can I make an name for myself”. The problem with all of these orthotics is that while some of them work for the parameters the creator made them, they all miss the mark as to why they work. And why they fail even though they may improve symptoms. The dental profession (just like the Cranial Sacral therapists, the Chiropractors, the MD’s) for the most part try to be the ruler of all they purvey. They can do it all themselves. Or, they choose to limit their view of their patient to achieve success in a very narrow parameter or scope of problems. What should be done is not looking at these various orthotics as an answer for patient care but as one part of a greater effort to help restore some physiology to the entire system … the head, neck, body physiology. Physiology is described as how the body solves problems. Any effort by any HCP should be to look past their own area of interest or expertise and coordinate with other HCP to help give the patient the best result.

Bjørn Hogstad
Chronic pain patients need an interdisiplinary team to deal with evaluation , diagnosis and it need an interdisiplinary team effort to deal wth the treatment aspect. Those groups who think they can do it all ,and all the symptoms are in their court, will fall short in their treatment success. No permant treatment should be done on any teeth untill the physical rehablilitation of the patient has been completed by the other interdisiplinary team members. and after an observation periode. Why?. Becuase you only have one shoot at getting the occlusion right. And you can not get the occlusion right unless the other structural part of the body have been corrected if necessary in advance of any definitive dental treatment, ansd are proven to be stable. Occlusal splints should in nearly all cases be full coverage in hard acryllic unless you want to experience supereruption of teeth not covered by the splint. The only exception is the anterior deprogrammer which can be used in accuted cases or to test if the pain is intraarticular in the joint or have a mucular origion The latter si only for short term use and should be monitored closely and followed up by the dentist . A split it self do not give permanent relief in itself. It is a method bu which you can stabilize the occlusion and get the TMJ and musculatur in a healthy state. As. soon as you remove the splint the condition is back to square one . It is just the same as if you have a heallift in your shoe due to one leg is shorter than the other. The heel left does not make the leg grow it just compensate for the length difference and it will only work if its in the shoe. The occlusal splint is very much the same. So it is only an intermediate appliance in order to create stability and so help the other part of the interdisiplinary team in their treatment endevour so their treatment can be more stable and at the same time it gives support to the muscle of mastiation and TMJ to keep them in harmony.

Curtis Westersund
Bjørn Hogstad, you make a good point about a hard splint and a contradiction to Jim Jecmen with regards to buying a soft orthotic from Walmart. The neurology works that when something is soft in the mouth the jaw wants to chew it. Play with it. You cannot firmly bite on a soft orthotic and since there is not secure endpoint you activate your masseters more and in many TMJ patients, this creates a further fatigue symptom in the masticatory muscles. Perhaps for a few hours (we use aqualiners when transferring patients between my NUCCA chiropractor Dr Jeff Scholten’s office and mine, but even then only with severely unstable patients.
If you want to let the musculature relax, let the jaws close in a physiologic position and have a physiologic rest position where the CCMC is stabile and balanced.

Bjørn Hogstad
A danish studey if I remember right in the 70`I think is was showed that interferrences of 50 microns is enough to set up muscular hyperfunction. When I adjust the occlusal splint I use a 12 my foil. Do Walmart do that for you? For muscular release and reduction in hyperfunction precision in fit is absolutely essential. With a soft splint you will have lateral interferences .

Curtis Westersund
The latest study I have seen is 11 microns to 20 microns from a tooth to an implant Bjørn Hogstad

Bjørn Hogstad
Curtis Thanks for the feedback

Eva Willer-andersen
Curtis Westersund I am interested in your last comment about from a tooth to an implant what do you mean exactly ? I have a bridge on implants spanning 9 lower teeth . Thanks

Julian Piccolo
I have a few questions in regards to treatment using splints and I was wondering if anyone could chime in and give feedback. So I now have developed severe TMD, I also have very contracted muscles in my face and neck. My neck basically is in a statement of whiplash. I have arthritis in my jaw joints and severely so in my right joint where there are bone spurs sticking to the joint. My pain is severe at this point.
Given that information, am I a candidate for splint therapy, or am I too far gone? One of my dentists has said I would need to get surgery before splint therapy because the bone spurs would disrupt splint therapy and it just wouldn’t work. Of course, I am scared to get the surgery as I know it can be extremely painful and can sometimes make the condition much worse. Is it true that bone spurs make splint therapy impossible? I have constant bone on bone scraping/contact and the joint is very inflamed and painful. I feel desperate to get the joint off of the bone so I can begin some kind of healing process. Thoughts anyone? I would greatly appreciate a response! Thank you.

Bjørn Hogstad
Splint therapy first —always ..-always then evaluate .

Curtis Westersund
Well Bjørn Hogstad, let us not be hasty. I agree that orthotic therapy (splints are used to bring two broken things together. Orthotic is a better term) is probably required for Julian Piccolo, he may wish to have his CCJ assessed by an upper cervical chiropractor, have what ever physiotherapy done (did you have an MVA Julian Piccolo?) and try and restore some other physiology prior to taking a bite and making an orthotic. JMHO.

Curtis Westersund
Implants do not have a periodontal ligament (PDL). They are solid and do not move. Therefore when testing pressure sensitivity against a tooth touching and implant it would logically require 1/2 has much of a discrepancy than when two teeth with PDL’s are being measured

Julian Piccolo
Thank you both for your response. Unfortunately my feeling is that I may I have missed my chance to try orthotic treatment. I almost went into treatment 2 years ago with Dr. Jennings in Alameda (East Bay), but was talked out of it by a different doctor in SF, Dr. McNeill (UCSF). I have been getting NUCCA adjustments for 2+ years, at first it was great for pain etc, but now I loose the adjustment often and have experienced symptoms similar to cervical dystonia in my neck, right side, especially the SCM muscle. This added neck issue, as well as the joint instability/damage has contracted my facial muscles quite severely and about 4-5 months ago my jaw locked open. Since my jaw locked open I have no resting position, cannot close my mouth etc, and have been on the decline. I have had more spasms, and also losing my keep loosing my adjustment at times, which has really affected the bite. Plus it feels like the joint is really stuck on the bone spurs. Sadly, I feel like I missed my opportunity to get effective orthotic treatment and really wish I had not been talked out of it. Given the added neck problems, spasms, locked jaw (open), contracted muscles etc. Should I still think about trying the orthotic first, before surgery? Also, I can’t open wide, so getting impressions made is very difficult. Any thoughts? Much appreciated.

Curtis Westersund
Julian Piccolo, if it is the same Dr. Jennings I know then you are in good hands as he is a very smart dentist. You have a plethora of muscle symptoms. Dystonia of the cervical vertebrae is a muscle symptom. But it can be from a variety of sources all at once. Occlusion may be one. Your SI joint could be another at the other end. As I can not diagnose over the internet, and you are in California, look up Dr. Doug Chase as he is very knowledgable and may be able to shed some light for you.
Hope this helps.

Julian Piccolo
Curtis Westersund, thank you for your reply I really appreciate it. I will continue to consider Dr. Jennings as a possibility. I might have seen Dr. Chase already, he’s in Walnut Creek. He basically told me that he could not help as it would be too difficult to get impressions.
Yes, the cervical dystonia is a tricky problem, it is definitely related to occlusal as well as the upper cervical. I will check out your website and email you some photos for further opinion. I am trying to get as much insight as I can at this point.
Thanks again!

Eva Willer-andersen
Curtis Westersund thanks for answering . Sorry I still don’t understand all of it ‘Curtis Westersund Implants do not have a periodontal ligament (PDL). They are solid and do not move. Therefore when testing pressure sensitivity against a tooth touching and implant it would logically require 1/2 has much of a discrepancy than when two teeth with PDL’s are being measured’
I get the PDL bit but not the rest …so much less pressure contacts on the implants 1/2 the pressure of natural teeth ? so if you have an implant bridge on one lower half of dental arch and natural teeth on the other how do you deal with that ?

Curtis Westersund
Eva Willer-andersen, you deal with this accurately. Tscan sensors are 90 microns. Tooth on tooth can feel less than 50 microns. Tooth on implant can feel as low as 11 microns for around 40% of the test subjects. Close to 99% for 20 microns. So you have to realize that implant sensation should not be ignored. Contact with an implant should happen only when the other teeth are under full compression. Tscan helps with this.

Bjørn Hogstad
Curtis I think we agree. I use occlusal splint ( which should really be called temporo -manibular – cervical – orthopdec splint. Because these are the areas it’s affect) Initially I use the splint to the get the condyle in Its proper position in the joint space, I remove the effect of the occlusal prematurities that forced the lower jaw into maximum intercuspation. This eliminated the hyperfunction in masseter, temporalis, pterygoideus lateralis and medialyset. We also see the reduction of hyperfunction in Sternocleidomastoideus an bekk muscles and trapezius. This then gives the chiropractor a better starting point to work on the Columna totalis to try to correct that. Then you need the rehabilition of the muscles and eliminating myofascial trigger points and muscle hyperfunctening and stretching the muscles . My Job as a dentist as this goes on is to make sure the occlusal splint is stable. I have found that If the splint goes in g
First and stabilize the areas mentioned above the treatment goes faster and are more stable by the chiropractic and physioterapeutic treatment. You still need to go that route Even If surgery is conciderable. I always recommend this procedure before invasive surgery is being started in most cases.

Sophia Christodoulou
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