A Case For Conservative Treatment, Or, Controversies In Dentistry: Part II TMJ Treatment

July 18, 2018

“I have TMJ.” Dentists hear this every day. The good news is, not only do you have TMJ, you have two. TMJ stands for TemporoMandibular Joint, more commonly known as our jaw joint, which resides just ahead of your ear tragus. You know the tragus – it’s the part of the ear that the kids love to pierce. It’s also handy for holding in earbuds. Place your fingers just ahead of your tragi, open and close a few times and you will have successfully identified your temporomandibular joints. About 1 in 3 of you will notice a click or pop in 1 or both of your joints when you open and close and if you’re lucky, it won’t cause any pain.

In the dental profession, we usually refer to TMJ as TMD or TemporoMandibular Dysfunction, which is an umbrella term for a collection of problems with the jaw joints, muscles, tendons, cartilage and ligaments. It’s the most common orofacial pain and is experienced by men and women, young and old. Some estimates suggest over 10 million Americans experience some form of this condition. Diagnosis can be difficult and often takes time, possibly requiring multiple visits with multiple clinicians. If you’re unfortunate enough to have experienced this, you no doubt have heard many different treatment approaches, from not chewing gum to wearing a splint, to crowns, orthodontics and even jaw surgery. It can be confusing and overwhelming because in the midst of all this advice, you are in pain. You can’t eat, laughing hurts, your head aches, you don’t want to work or socialize and all this begins to weigh you down. Like other chronic pain sufferers, depression and anxiety are common in those with TMD.

And those who suggest treatment A vs. Treatment B or C are almost always certain they have the answers and that everyone else is nuts. Or dumb. Or misinformed. It gets pretty heated and causes rifts in professional and personal relationships. Seriously.

So, what are you to do? You want treatment that is effective, right? And if you’re like most people who experience chronic pain, you will do just about anything to have some pain relief. Let’s take 2 treatment approaches, but please remember, there are many other treatments that I am not going to discuss here. I am using 2 very real-world examples that occur every day in many dental offices and both claim to effectively treat TMD. The 2 treatment approaches are: Occlusal and non-Occlusal. You may now be wondering “What is Occlusal??” which is a good question. Occlusion is how our teeth come together, so in simpler terms, the treatments are a bite-centred approach and a non-bite-centred approach.

The bite-centred approach involves changing how your teeth come together and is often achieved by one or many of the following methods:

  • Full-time splint wear
    • Wearing a splint or “orthotic” full-time will change how your teeth come together. By doing this, you will commit to either braces to move your teeth to a new position as determined by the splint or crowns on many or all of your teeth. This is costly, time consuming and is often not without complication
  • Orthodontics (braces)
    • If you have worn an appliance full-time and have experienced a bite change, it may be recommended that you have braces to “stabilize” your bite to the new position. This is costly and time consuming, but is probably the most conservative of the bite-centred approaches
  • Multiple or full mouth crowns
    • If you have worn an appliance full-time and have experienced a bite change, it may be recommended that you have crowns on multiple or all of your teeth. This is expensive (often over $50, 000. Yes, you read that correctly), and often has complications, including root canal therapy and possible tooth loss. Never mind that it involves shaving down healthy enamel. And crowns will need to be replaced in around 10 years, which will cost another $50,000 (or probably more)
  • Jaw surgery
    • This may be on the joint alone or may be recommended in conjunction with orthodontic treatment and/or multiple crowns. It is costly, demands recovery time and is often not without complication

It should be noted that throughout most of its history, organized dentistry advocated the bite-centred approach. With the advent of evidence-based dentistry in the 1990’s (yes, we were a little late to the evidence-based party), it became glaringly clear that most (over 85%) of TMD cases had NOTHING to do with a faulty bite or “bad jaw position.”

Non-bite centred treatment does not try to change your bite. Instead, it takes the following approaches.

  • Home-based physical therapy
    • Passive stretching
    • Heat/ice
    • Avoidance of painful triggers (e.g. hard/chewy food)
    • Relaxation therapies
    • Posture awareness
  • Part-time splint wear
    • Worn only at night, this will likely not result in any permanent changes to your bite. The idea is that it will decrease your tooth grinding (initially) and hopefully reduce some of the stress on your jaw joints
  • Medications
    • Non-steroidal anti-inflammatory drugs (NSAIDs), like Ibuprofen; steroid anti-inflammatory drugs; medicated topical creams; short-term antidepressant use; short-term anti-convulsant use
  • Trigger point injections and needling
    • Pioneered by Dr. Janet Travel (President JFK’s physician), a small amount of lidocaine (i.e. “freezing”) is injected into the painful part of the muscle, which typically offers pain relief for days, weeks or months
  • Joint injections
    • If a TMJ is not responding to the above therapies, we may inject a joint lubricant or a steroid, similar to someone with knee arthritis
  • Physical therapy
    • Some people also require treatment with a physical therapist to manage their neck and jaw pain
  • Botulinum toxin injections (i.e. Botox)
    • Botox has been shown to treat chronic migraine, nerve pain and muscle pain. If other, more conservative treatments are not effective, some people require botulinum toxin to manage their pain

Most people who pursue the non-bite approach may spend $1000 – $5000. If botulinum toxin is required, treatment may cost up to $10,000 (unfortunately, Botulinum toxin is very costly to provide). It should be underscored that no enamel is sacrificed with the conservative, non-bite change approach; there is very little in the way on long-term follow up; and there are few, if any, treatment complications.

The Evidence for TMD treatment: Well, that’s a good question. According to the American Dental Associations Evidence-Based Dentistry site, bite changes are not recommended. According to Nature’s Evidence-Based Dentistry, bite changes are not recommended. According to the Canadian Dental Association, bite changes are not recommended. According to every provincial dental association, including the Alberta Dental Association and College, bite changes are not recommended. Most (all?) Oral Medicine/Orofacial Pain graduate programs in the USA, Canada and the UK recommend no bite changes.

So, conservative non-bite-centred treatment has the endorsement of most (all?) organized dental bodies, NIHB research and graduate dental programs the manage TMD with no irreversible changes to your teeth or jaws. Bite-centred treatment is not endorsed by any dental organizations like the Canadian or American Dental Associations, is very costly and requires extensive ongoing follow up.

Considering this information, can someone please explain to me how there is still a controversy?

References

Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005514.
Occlusal splints for treating sleep bruxism (tooth grinding). Macedo CR1, Silva AB, Machado MA, Saconato H, Prado GF.

J Oral Rehabil. 2010 May;37(6):430-51. doi: 10.1111/j.1365- 2842.2010.02089.x. Epub 2010 Apr 20.
Management of TMD: evidence from systematic reviews and meta-analyses. List T1, Axelsson S.

Quintessence Int. 2004 Mar;35(3):211-21.
Association of malocclusion and functional occlusion with temporomandibular disorders (TMD) in adults: a systematic review of population-based studies. Gesch D1, Bernhardt O, Kirbschus A.

Angle Orthod. 2007 May;77(3):542-8.
TMD in relation to malocclusion and orthodontic treatment. Mohlin B1, Axelsson S, Paulin G, Pietilä T, Bondemark L, Brattström V, Hansen K, Holm AK.

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