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TMD (Temporomandibular Disorders)

During your comprehensive exam, we dis-cover that you have problems with your bite,

with jaw muscles, with your jaw joints, or all.You may suffer from what is known as Tem-

poromandibular Disorder or TMD. TMD/Occlusal therapy is suggested as part of the

initial work we do together.

What Are Temporomandibular Disor-ders?Temporomandibular disorders (TMD) areoften called "TMJ" although this term TMJrefers only to the jaw joint themselves. TMD/TMJ describes a group of diseases that caninvolve the Masticatory System(see Dia-gram 1). TMDs are physical disorders aris-

ing from an imbalance in the delicate workingrelationship of the jaw and skull with themuscles that attach to and move the jaw aswell as the nervous system associated withthese systems. This imbalance results in mus-cle fatigue, spasm and/or joint dysfunctionand even changes in the teeth, which in turncauses a variety of symptoms, unique for each

person.

How Is It Caused?

Trauma- Acute trauma to the jaws such as acar accident, a fall, a punch, etc. can causedamage to the muscles and/or joint. The acute

From the Office of Dr. Michael J. Guy 511A Lakeshore Drive, North Bay ON, P1A 2E

pain and loss of function is usually respon-

sive to conservative treatment. Sometimestrauma to the joint can cause chronic dam-age which may eventually contribute to aTMD problem at a later time.

Bruxism- Bruxism refers to a non func-tional grinding and clenching of the teeth.Some do this while awake but more often itis done while sleeping. Most people grindtheir teeth while sleeping to some degree.For whatever reason some people do thisvery hard to the point where they wear theenamel from their teeth. This bruxing isdone by the jaw muscles and by the morn-ing they can be painful due to fatigue. This

constant pressure also can damage theTMJs over time. Bruxism is the most com-mon factor found in TMD.

Malocclusion- This term means "bad bite".Perhaps the best way to understandmalocclusion is to understand what an idealocclusion is.It is the type of bite we refer to as aminimal stress, minimal adaptation, leastdestructive type of bite. It occurs when:

your temporomandibular joint (TMJ) isseated fully into the socket (fossa), in acomfortable, relaxed position and whenthe muscles are relaxed all of yourteeth should touch simultaneously.(Note in diagram 1 on the good bite thered dot is in the middle of the cross andthe teeth in a full bite)

When you squeeze firmly from thisrelaxed position, there should be noshifting of either the jaw or individualteeth.(Note in diagram 1 on the poor bite the

jaw had to shift forward to achieve afull bite- the red dot is forward of thecross)

This harmony between the TMJs and the

teeth is the most important requirement forcomfortable, stable bite. Any disharmony

between the TMJs and the teeth requires thjaw muscles to hold the jaw joint out of itssocket in order to completely close the teettogether which can lead to muscle fatigue asoreness..

Bad habits- The same habits of poor postuthat lead to back, shoulder and neck problecan also contribute to TMD. Other habitssuch as leaning your chin on your hand, excessive gum chewing, pencil biting, etc canalso lead TMD problems.

Emotion - Emotional stress often plays anintegral role in the development of TMD.This occurs due to two basic reasons. Stresincreases both the severity and duration of

bruxism while asleep. Also, many will subconsciously clench and/or grind their teethmore while awake during times of stress. Tother way stress contributes to TMD is thaduring times of stress your adaptability and

pain threshold will go down. As a result yoare more likely to experience symptoms ofTMD if other factors already exist (bruxing

joint damage, etc.). Emotional conditionsbeyond daily life stress can contribute toTMD as well. Depression, anxiety disorder

and the like can often have TMD problemsarise. These conditions are quite stressful a

it is not hard to imagine why TMD wodevelop.Various Health Problems- Certain diseascan cause or aggravate TMJ problems. sucas rheumatoid arthritis or oesteo-arthritis,Fibromyagia , etcWhat Are The Symptoms?

Table 1 shows all the possible signs and

symptoms of TMD.

It is the chewing system, which includes yourteeth, the periodontal support of the teeth, thetemporomandibular joints (TMJs) that facili-tates the movement of your lower jaw, andthe muscles that actually move the jaw.Together they form a highly integrated, bio-mechanical system. They are so integrated,any problem in one area of the system, creat-ing an imbalance, will most likely lead to

problems in another area of the system.

Diagram 1: Masticatory System

1

Diagram 2: Proper Bite to Poor Bite

PROPER BITE POOR BITE

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Table 1

Symptoms of TMD Jaw muscle pain or soreness, more no-

ticeable in the morning or afternoon

Jaw muscle pain while chewing, biting,or yawning

Earache without an infection, sometimesspreading into the face

Aching on the side of the head and neckpain

Tooth wear

Tooth Sensitivity and pain

Sensitive teeth without any signs ofdental problems

Breakdown- cracking and crazing,scooping defects at the neck,

loosening, of teeth

nerve damage

Gum recession

Bone defects around teeth

Jaw-Joint Pain,

Locking" of jaw in an open or closed

position A clicking or grinding noise while open-

ing and closing your mouth

Difficulty opening and closing yourmouth or restricted jaw movement

A stiff jaw when eating, talking, or

yawning

Bite and TMD ExaminationProper diagnosis is critical to make sure you

receive treatment for your particularcondition. We only recommend treatmentafter conducting a thorough health history,clinical exam, taking appropriate X-rays, and

perhaps confirming the condition throughother diagnostic tests.

History Questionnaire

We are looking to see if you have had previ-ous trauma, surgery or any other treatmentsfor a condition that may have been over-looked and TMJ diagnosis was not consid-ered. We also look for a positive history of

being treated for a TMJ disorder and whetherit was handled effectively.

Jaw-Joint Examination

This determines if the jaw joints are healthyand functioning properly and includes physi-cal tests on the TMJ such as:

Palpation (pressing various areas),

Doppler Auscultation (listening forsounds while the jaw moves). Doppler

can detect joint sounds (and thereforejoint problems) in their early stages.

Loading or joint compression tests(using a gentle technique called"Bilateral mandibular manipulation").

Range of Motion MeasurementsThe mandible has a normal range of motionthat should be attainable in opening andclosing. It also has a normal range of mo-tion that should be attainable in sliding tothe left and to the right. The mandibleshould also be able to opening and close in

an up and down path that is straight withouta deviation to the left or to the right. Rangesthat fall below the norm are usually indica-tive of incoordinated muscle function butcan also be representative of an internal

joint problem.

Muscle ExaminationHere we are palpating the mucles of masti-cation and associated muscles connecting tothe mandible, skull, neck and back. Positivemuscle soreness is a sign of fatigue andspasm

Study Models and Evaluation of your

biteThis examination determines how the upperand lower teeth function (or malfunction) inrelation to one another. We will take im-

pressions (moulds of your teeth). Themoulds are then attached to an articulator(jaw simulator) for further evaluation. Thishelps us to determine: The proper and/orimproper alignment of the teeth and jaws,where the premature contacts are on yourteeth that can cause fractured teeth or head-

aches, proper relationship of your teeth tothe rest of your head and the excessivewear patterns on teeth

Costs For Examination

TMD TreatmentTreatment may be simple or require moresteps for alleviating the condition, dependion the degree of severity. Some of thesetreatments include:

Wearing a splint to eliminate the harmeffects of clenching or grinding the te

and a better positioning of the jaws

Self-care- Eating soft foods, avoidingchewing gum, applying moist heat or

Taking a non-aspirin pain reliever orprescription medictions such as musclrelaxants, analgesics, or anti-

inflammatory drugs

Physiotherapy- Jaw and neck exercise

and Posture training

Stress Reduction Biofeedback and Rlaxation techniques to control muscletension .Stress management training

techniques

Adjusting the bite, known as "occlusequilibration" involving removing intferences when the teeth touch It involdirect reshaping of the biting surfacesgrinding and polishing selected toothsurfaces that interfere with comfortab

jaw movements. When correctly doneproperly selected patients, it is a cons

vative and effective treatment.

Replacement of defective restorationsthat prevent the jaws from meeting prerly Teeth that are badly worn or that

need the biting surfaces re-shaped maneed crowns or other types of

restorations.

Orthodontics, to put the teeth in propeposition

Surgery -In extreme cases where thejoint has been badly damaged, appliantherapy will not work. In this instancewe may refer you to an oral surgeonwho is specially trained in surgicaltreatment modalities. Surgicalintervention is only necessary whenthere is no other choice and happens i

less than 1% of cases.

TMJ Exam, Treatmentplanning and consultation

01204 105.00

Mounted Diagnostic Casts,facebow, Occlusal records

04922 130.00

Bilateral mandibular manipulation

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chew gum or eat hard (raw carrots ) orchewy foods (caramels, steak, begals).

Cut foods into smaller pieces and avoid

foods that require wide mouth opening a

biting off with the front teeth. Evenly divide the food on both sides of

your mouth and chew on both sides.

Avoid caffeine, because it stimulates yo

muscles to contract and hold more tensioin them. Caffeine or caffeine-like drugscoffee, tea, most sodas, and chocolate.Decaffeinated coffee has some caffeinewhile Sanka has none.

Other Habits

Try to hold your head straight. Good he

neck and back posture help you to havegood jaw posture. Use a small pillow orrolled towel to support your lower back.

Avoid habits as resting your jaw on your

hand or cradling the telephone against yshoulders.

Avoid sleeping habits that strain your ja

muscles or joints, by not sleeping on youstomach and if you sleep on your side,keeping your neck and jaw aligned.

Support the jaw during yawning by prov

ing mild pressure underneath the chin wthe thumb and indexfinger or back of thehand

TMJ ExercisesThe TMD exercises are designed to help re

Depending on your condition the initial

step in treating TMD can involve some or

all of the following: self-care therapy,

splint wear, medication and other profes-

sional therapy.

Self-Care TherapyThe following will help instruct you on howto relax your jaw muscles and joints to reducethe jaw pain you are having.

Position the jaw to avoid tooth contacts

Place the tip of the tongue behind the topteeth and keep the teeth slightly apartMaintain this position when the jaw is not

being used for other function such as speak-ing and chewing

Awareness of habits or jaw use patterns:

Closely monitor your tooth contact. Avoid

tooth contact except during chewing andswallowing

Closely monitor habits such as: clenching,

grinding, gritting, tapping of the teeth ortensing or holding the jaw muscles rigid.Monitor tooth clenching during daily ac-tivities such as driving, studying, computerwork, social situations, reading, overworkand fatigue, stress, at work or engaging inathletic activities

Do not test the jaw

Do not open wide or move it around exces-

sively to assess pain or motion

Avoid habitually maneuvering the jaw

into positions to assess its comfort orrange.

Avoid habitually clicking the jaw if one

is present

Heat and Ice Therapy

Apply moist heat, ice or a combination ofheat and ice to the painful areas. Most peo-

ple prefer heat but if that increases yourpain use the combination or just the ice.

a. use moist heat for 20 minutes two tofour times each day. Moist heat can beobtained by wetting a towel with verywarm water. It can be kept warm bywrapping it around a hot water bottle or

placing a piece of plastic wrap and heat-ing pad over it. It also can be rewarmed

in a microwave oven or under the verywarm water.

b. Use the combination of heat and ice twoto four times each day. Apply the heatas recommended above for ten minutesthen lightly brush the painful area withan ice cube wrapped in a thin wash-cloth. Repeat this sequence four or fivetimes.

c. Apply ice wrapped in a thin washclothto the painful area until you first feelsome numbness then remove it (usuallytakes about ten minutes).

Diet

Choose softer foods and only those foods

that can be chewed without pain. Dont

INITIAL TMD THERAPY

Hold this pose for five seconds.Try to make this position your regular pos-ture.EXERCISE FOURTuck your chin against your chest. Youshould feel the muscles on the back of youneck stretching.Hold the position for five seconds.

EXERCISE FIVE

Stand up.Push your head back until your shoulders ahead are in a straight line.Tuck in your chin.Hold for five seconds.

EXERCISE SIXStand up.Place the back of your right hand in the cenof the small of your back.Put your left hand across the front of your

body and grasp your right side.Tuck you chin and rotate your head to the lHold position for ten seconds.

TMJ EXERCISES

EXERCISE ONEThe first exercise is an isometric one and

should help the muscles that move your

jaw work together better. Do six repeti-

tions, six times each day.

Open your mouth the width of your indexfinger.Place your finger on the top of your lower

front teeth and press down.Do not allow your jaw to move, Resist the

pressure of your finger with the muscles ofyour jaw.Keeping your mouth open the same distance,

place your finger under your chin. Applyupward pressure and resist it with the musclesof your jaw.

Now try pressing from each side.Use only one finger for pressure.Apply the pressure for only five seconds at atime.

EXERCISE TWOThis exercise will help you to open your

mouth without causing popping, grind-

ing, and pain in the joint. Practice it until

you know how wide you can open with

comfort. Then, stick to those limits.

Place your tongue against the roof of yourmouth.Open as far as you can without allowingyour tongue to move.

If you hear any popping or grinding, closeuntil the noise stops.Repeat the exercise, opening only as far asyou can without making any noise.

The following exercises, which stretch

and strengthen your head and neck mus-

cles, also relieve pressure on your nerves.

Practice them several times a day.

EXERCISE THREERotate your shoulders back and down as faras you can.

From the Office of Dr. Michael J. Guy 511A Lakeshore Drive, North Bay ON, P1A 2E3

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These will be sent to the dental lab forfabrication of the splint. This will takeone to two weeks.

2. At the second appointment the splint willbe fitted on the lower teeth and the biteadjusted precisely to the upper teeth.You will then be given instructions forwear

As the muscles relax, the bite on the splint

may change. Follow-up appointments dur-ing this trial period are necessary to monitoryour progress and to adjust the splint if it isnecessary. If at any time you feel your biteon the splint changes drastically, call our

office and we will try to schedule you withan earlier appointment.

NTI-tss

The NTI-tss is fitted to your two upper frontteeth and is worn only while you sleep. The

NTI-tss takes about 15 minutes to fit andadjust. The NTI-tss takes advantage ofyour reflex reaction. When your lower teethhit the device a signal is sent to the jawmuscles to reduce contraction. By wearingthe NTI clenching intensities are reduced by

66% of full power helping muscles relax.

How much does a splint cost?The average cost of a splint therapy willrange from $600 to $700. Dental Benefits

and eligibility will vary from one carrier tothe next. However, to be sure our officewill send a pre-determination to your dental

benefits company to find this out.. The fol-lowing table is a breakdown of the fees

Instructions

lieve the pain and stress you have in yourjaw muscles and jaw joints. Practice theseexercises as described below.

SplintsA splint is a hard acrylic appliance that iscustom fabricated to fit snugly over eitheryour upper or lower teeth. A splint cancover all the teeth on one jaw (full) or onlya few (partial).

A splint serves many purposes:

1. It helps tense jaw muscles relax. With thesplint in the jaw is freed from the toothinterferences that may be contributing tosore muscles and can settle in a morecomfortable position

2. The splint protects your teeth from theharmful effects of parafunctional habitssuch as grinding and clenching.

3. The splint aids us in arriving at a diagno-sis. Whether you become more comfort-able after wearing this splint or not has adefinite bearing on whether your problemis bite related. Only after your symptoms

subside will a more permanent method ofimproving your condition be suggested.

We use two types of splints in our office:

The lower full splint and the NTI-tss. We

may recommend either one or both.

Lower Full Splint

The lower splint covers all your lower teethand the biting surface is meticulouslyadjusted to fit as perfectly as possibleagainst the opposing teeth. When the splintis in, the jaw should close with even toothcontacts.on all your upper teeth.

The lower splint requires two one-hour

appointments:

1. At the first we will take models of yourteeth and a registration of your bite.

Lower Full Splint + Lab 14612 $350.00

NTI-tss 14612 $250.00

Splint adjustment appoint-ment (15 minutes)

14621 $50.00

Please wear the splint as instructed.

Please wear splint at night to protectteeth and jaw muscles from grinding anclenching.

Please wear splint as much as possibleuntil symptoms are relieved and a diag-nosis can be determined

Care for the SplintAt least once per day (especially upon awak

ening), brush the splint with a soft toothbrushand a creamy soap solution. Mouth washmay also be poured over the splint.

Medication Advil or Motrin 600 mg, three times

day with meals

Valium 2 mg three times/day

Elavil 10 to 20 mg at bedtime

Additional Professional Care Physiotherapist (Symetrics)

The Physiotherapist will assessment yourposture, the biomechanics of the TMJ, an

craniovertebral junction, evaluate habits(grinding, clenching, etc.) and breathingand swallowing patterns. The treatmentwill focuses on functional restoration ofthe biomechanics of the head, neck andcraniomandibular system using RocabadoTechniques.

Clinical Psychologist

The Clinical Psychologist will use sev-

eral techniques to help you relax. The

most common is:

Cognitive Behavioural Therapy (CBT)

If the cause of facial pain is through achronic bruxing habit, CBT is used to helyou replace the bruxing habit with betterstress coping mechanisms.

What success can I expect?These initial measures set up conditions forhealing; the rate of healing or whether healinwill occur at all is dependent upon your indi-vidual problem, physiological make up andyour compliance or cooperation . Eventhough our success rate is very high, there arno guarantees that this therapy will provesuccessful for you. If several weeks of ther-apy does not appreciably improve your condtion, we will discuss other modes of therapywith you at that time.