If you experience unexplained headaches, especially in the morning, you may have a problem with your temporomandibular joint. Such pain is often referred to as TMJ or TMD (temporomandibular joint disorder). Mild TMJ/TMD pain can often successfully be treated with over-the-counter pain relievers.

TMJ/TMD pain is experienced by millions of Americans, the majority of them female. Suffering in silence is a common practice of many people affected by this condition. The pain caused by the disorder can be localized in the jaw or it can radiate out into other parts of the head and upper body.

Sometimes earaches can also be associated with TMJ/TMD.

The exact cause of this condition is not known; however, the resulting pain can be attributed to several different factors including:

• Stress that leads to involuntary clenching of the teeth, producing additional stress on jaw muscles.
• Arthritis
• Bruxism
• Dislocation of a cushioning disc of cartilage where the jaw connects to the cranium
• Injury to the temporomandibular joint

Treatment of TMJ/TMD can alleviate the pain and improve your quality of life. When daily activities are impacted by jaw pain, it is time to seek relief and find a solution.

Jaw Pain, Facial Pain Relief!

Treatment for TMJ/TMD is available, although in many situations, the pain may resolve on its own over time, especially if temporary stress is causing you to clench your teeth. In these situations, once the stressor is removed, the clenching stops and so does the pain.

When TMJ/TMD pain is severe and/or chronic, treatment is available. Dr. Perkins has experience in treating TMJ/TMD and can provide you relief from the discomfort. Individuals experiencing chronic stress may benefit from learning to relax and practicing stress-relieving exercises to help ease the muscles.

Get an Accurate Diagnosis

Your first step in alleviating the pain caused by TMJ/TMD is to get an accurate diagnosis. Jaw pain can be caused by other conditions, so it is important to identify the cause of your pain. Ruling out certain conditions is important. Keep in mind also that long-term use of OTC pain relievers can have a negative effect on your health, so it is important to have your pain diagnosed and treated as soon as possible. Make an appointment with Smiles in Malibu, and Dr. Perkins will diagnose your condition and recommend effective treatment.

More About TMJ

First off, what is TMJ?

TMJ is an acronym for Temporomandibular joint. The joint in front of the air on either side of the head that controls the lower jaw movement. When people say they have “TMJ” they are really referring to pain or dysfunction associated with the jaw. This could be:

• Headaches/migraines
• Neck pain
• TMJ noise
• TMJ pain (in the joint)
• Ear congestion
• Ringing in the ears
• Dizziness
• Limited opening
• Tightness

Technically you have a disorder that is most specifically related to your bite. Everyone who I tread for “TMJ” or sometimes knows as TMD (temporomandibular disorder) has a problem with their bite. Their bite is forcing muscles to overwork for causing the TM joint to over compress or creating some dysfunction such that muscles are overworking and pain ensues. Sometimes there is an imbalance in a person’s “bite’ which is causing dysfunction or pain. Invariably TMJ is associated with a person’s bite.

Muscles are overworking and they become fatigued and painful. When this happens in a specific area other muscles in the surrounding areas will often try and “help out” and they start engaging to take some of the load and then they become fatigued, painful, etc.. This is why headaches and neck pain and even shoulder pain can often accompany the dysfunctional bite. This is why we associated headaches and neck pain often with TMJ. If the bite is not in the correct place the joint is often affected as well because everything that affects the bite will also affect the relationship between the condyle and the fossa. The joint is made up of the fossa (part of the skull), the condyle, the end of the mandible, and the disc which is positioned between the fossa and the condyle.

Diagram
The bite is very unlike any other dynamic in the human body. It may be the only joint or physiologic system that is not determined by genetics. By contrast, your eye color and hair color, etc., are 100% genetically determined such that any environmental or developmental input will not change their manifestation.

The bite is totally different in that it is very sensitive to developmental and environmental conditions. Without a doubt the most power developmental force on the bite is whether you are breathing through your nose or your mouth. IF you are a nose breather you will have a totally different bite than if you were a mouth breather. We have said this before but it bears repeating. Your face will look different and your ability to breathe will be impacted. Your bite can also be greatly impacted if you are a thumbsucker, if you were breastfed vs. bottle fed. If you ate solid foods as a developing child that required you to chew vs. eating soft foods that are often blended. But, without a doubt the main determinant is nose breathing vs mouth breathing.

IF you are a nose breather it is very likely that your bite will develop according to normal uninterrupted genetics. That is, your teeth will be relatively straight, the face will be proportional with a good airway. Your upper archform will be wide with plenty of room for the tongue, et. Your upper teeth will show when you are talking.

If, on the other hand, you are a chronic mouth breathier then your bite (and your jaws) will likely be more retruded. More recessed in your head and face. This is because when our mouths are open predominantly during the day and night there is an inward and downward force on our maxilla and mandible. This inward and downward force can act to angle the upper front teeth back into the face due to the lack of the tongue being positioned up against the roof of the mouth AND the ability of the upper lip to put inward pressure on the upper teeth (and cheekbones and nose) that is not counterbalanced by the tongue and the seal of the lower lip. Be aware that the skin that surrounds the face has weight to it. It is not insignificant. IF you mouth is open there is a pulling down and back of the skin of the face…that wouldn’t exist if the mouth was closed. The constant pulling down force on the upper front teeth pushes them back in the face and changes their angle in many cases. Because the lower jaw is back (as it opens it moves clockwise and instead of it being at 3 o’clock it is at 5 o’clock. This is further back then 3 o’clock. The upper and lower teeth will now come together in this position in many cases and it will result in a longer face (because the teeth won’t touch until much later). Keep in mind that when the mouth is open the tongue is never where it should be (resting up against the roof of the mouth). The tongue will then sit somewhere else and depending on where it habitually sits in the mouth (everyone is different) the bite and face will assume different positions and appearances. If a person postures their tongue (subconsciously) between their upper and lower teeth when at rest then the teeth will not erupt as programmed genetically and the bite for that person will likely be more compressed than it should be. This is because the teeth won’t be able to erupt full so they will not be as long as they should be and so when this patient closes down their face looks compressed. This often results in a deep bite. IF a patient tends to posture their tongue at the floor of the mouth (and not between the upper and lower front teeth) their bite will still be retruded but the teeth will now be able to over erupt because the tongue won’t be impeding their eruption yet there is still excessive space between the upper and lower teeth. Teeth want to erupt until they hit something.. When your baby tooth falls out you surely noticed that there was a permanent tooth peaking out through the gum…within a few weeks that tooth was now coming further out of the gum and within a short time that tooth would continue to erupt until it hit something…ideally (and according to the factory setting) the tooth would continue to erupt until it hit the opposing tooth. In a chronic mouth breather the tongue can interrupt this process by chronically sitting between the upper and lower back teeth and preventing their full eruption. IF the space between the teeth is excessive (due to the mouth being open) and the tongue is not impeding their eruption then the teeth will erupt excessively before contacting. This results in a long face. This usually manifests with a gummy smile (excessive gum tissue showing). This is because the upper teeth erupted excessively to the point where the gum came down too far. There was nothing to tell the upper teeth to stop eruption (the tongue and the lips were absent to bring about the proper end to the eruption process.

The bite is merely the position where the teeth come together. In most people I would maintain that their bite is not in it’s best physiologic position due to being altered by the aforementioned developmental and environmental forces. The vast majority of dysfunctional bites exist because the bite is too far back in the mouth. Remember, the muscles are left with the responsible of making the lower jaw come together with the upper jaw in this “bite”. It requires excessive muscle work for the muscles of the jaw to bring the mandible back into a retruded bite in the same way that it requires excessive muscle work to raise your arm above your head or raise your knee to your waist when walking. Imagine if you walked with your knee coming all the way up to waist level with every step. This is very fatiguing and within a short time your hips, legs, etc., would become fatigued. The relaxed way to walk is the way most all of us walk. It requires the least amount of work. If your bite is retruded in your face then your jaw muscles will to work excessively (beyond normal function) in order to get the jaw back so that the teeth can come together in that bite. These muscles will become chronically fatigued and will often result in TMJ symptoms of one form or another. To correct for this condition we would want to establish a new bite position (the correct physiologic position) where the muscles do not have to overwork in order to bring the teeth together in the bite. They simply have to close the jaw down. The muscles can completely relax until asked to function during eating or speaking. IF you are in the proper physiologic bite you will have certain muscles will very rarely ever be asked to work (the muscles that pull the lower jaw back). Those muscles, however, will work excessively if your bite is retruded. They will be tight, tender, often spasm and even lock at times.

Your teeth will come tougher at an early age in a position that the muscles will have to live with. If your teeth had a chance to consult with the muscles before forming the bite the muscles would certainly want a strong say as to the final position of the bite. The muscles will be tasked with accommodating that bite and the muscles often go “on strike”.

The disc
There is, as aforementioned, a disc that resides between the condyle and fossa. This disc cushions the joint and oves with the condyle always staying between the condyle and the fossa. This disc has a muscle attached to it and when this muscle is overly tight (as is the case with a retruded bite) then this disc gets pulled out of position. Usually into a position in front of the condyle. This means that it no longer moves with the condyle and it no longer acts as a buffer in the joint. IN this case the condyle moves over the disc and it makes a clicking or popping sound. This will persist until one of two things happen:

The muscles attached to the disc is relaxed (as a result of establishing and new bite) and the disc goes back into itse proper place.

OR, the disc gets destroyed as a result of constant traumatic engagement with the condyle. When the condyle is excessively damaged and eroded the clicking or popping sounds will often go way. This isn’t a sign that the problem is fixed. This means that the disc is irreversibly damaged and that bone on bone contact is down the road. This could bring about severe symptoms for many people. The lack of a disc in a dysfunctional bite position can create intolerable pain. Treatment for this would be to establish a bite that allows the muscles to relax AND to allow the condyle to decompress. This will often be enough to alleviate the symptoms even without having a disc. In my opinion surgery is very rarely the option for anything having to do with TMJ. IF you don’t establish a bite that allows the muscles to relax and doesn’t force them to work excessively then you are only treating symptoms.

Prevention
Prevention of TMJ is rather simple at its most basic level. Ensure that the teeth are allowed to erupt properly as per the position resulting from a lips together posture with the tongue positioned up against the roof of the mouth. Look at any face that you feel is very well proportioned, the teeth are showing and the smile is broad. You can surmise from this that this person almost certainly is a chronic nose breather. Conversely, if you see faces that are poorly proportioned or where the teeth don’t show, etc., then you can assume that that person is a mouth breather…it’s that simple.

Grinding of the teeth can also provoke and TMJ type condition (pain in the joint or muscles). Grinding of the teeth is often associated with an airway obstruction such that the grinding is a subconscious way of opening up the airway. Airway, as important a topic in this book as anything, is the body’s high priority such that if there is an impediment to the airway the body (or your subconscious mind) will often attempt to remedy the lack of airway. (class III) If you have enlarged tonsils such that your airway is blocked many people will subconsciously bring their lower jaws forward (underbite) because it allows more air to get in. Additionally, many people will position their head more forward (forward head posture) as a response to an obstructed airway. They don’t think about it but they learn subconsciously that if their head is more forward it will help to avert the blockage. Forward head posture is a sign of an airway issue. Forward head posture puts a big strain on the neck due to the fact that the head is no longer supported directly over the long axis of the body but instead it is projected forward in front of the body. This means that the typical 12 lb. head has to be supported much more by muscles. The head is much heavier essentially if it is not supported by the long axis of the body. The factory setting is for the human head to be atop the spine in a veritable straight line.

Since we are speaking of the spine let us not dismiss the role that the cervical spine plays in many TMJ cases. A person with TMJ will very often have subluxation of the top two vertebrae in the spine. This subluxation (dislocation) can make it challenging to alleviate all of the TMJ symptoms without addressing the cervical problems as well. The holistic nature of the body is very evident as it relates to TMJ, airway, cervical issues, etc.. We should always be looking at the forest…..I think we are taught to isolate trees too much in dentistry but we should always be willing and able to connect the dots that lead back to causation. Treating symptoms should be no substitute for treating causation.

Treatment
So, the previous paragraphs have hopefully foreshadowed the answer to the question of treatment of TMJ problems. First and foremost a new bite position needs to be established. IN my strong opinion in almost all cases this means more than adjusting the bite in it’s present position, It is true that TMJ symptoms can be provoked by a new crown that is too high (hitting prematurely). There are other circumstances where the bite does not need to be changed but where balancing of the bite in it’s present anterior posterior position will bring about relief of the TMJ symptoms. I have found in my practice that overwhelmingly my TMJ patients have retruded lower jaws and often compromised airways as well. Bites that provoke TMJ symptoms are all bites that create high muscle activity (EMG’s) and the answer is always to advance the bite position.

Typical orthodontic treatment of the last 100 years and counting is retractive by nature. The forces that would distort an ideal physiologic bite are all retractive. So, it is not surprising that virtually all bite corrections for TMJ involve establishing a bite that is more forward. This will also improve airway and enhance facial esthetics. “Form follows function”

Orthodontic practices have traditionally viewed the answer to crowded teeth is to extract teeth (usually 4) and then close the ensuing spaces left by those extracted teeth by pulling the teeth in front of the space back into the face. This is unfortunate on at least (3) levels. It is very provocative for the muscles because now the lower jaw is forced to be retruded from normal. The lower front teeth are behind the upper front teeth so if we bring the upper front teeth back we will force the lower jaw back from its natural place of neutrality. Also, if we ush upper front teeth back they will be angled in an unflattering angle. They will not be in a position to support the lip properly and they will be diminished in the smile. It matters a lot. Look at any smile that you feel is attractive and you will be sure that they teeth are very easy to see. They are supporting the lip.

And, if these two strong reasons aren’t enough to end tooth extractions for the purpose of straightening teeth we must add that when you bring teeth and jaws back into the face you limit tongue space and compromise the airway. There is no way to dispute this…

Bring faces forward…develop the airway. Let nothing compromise it…allow the lower jaw to be in a state where the muscles are neutral and aren’t asked to pull the jaw back. Allow teeth to show.

Indigenous cultures were and still are often blessed with the benefits of not being subjected to the impact of western culture. They will not be subject to the influences that obstruct the airway, lower tongue posture, cause mouth breathing and tooth crowding. They will have the balanced, proportional, and symptoms free faces that we all should expect.

Treatment involves changing the bite. This is non surgical and comfortable. Changing a bite should always be done on a temporary or trial basis until symptoms are fully abated. Then and only then can a new permanent bite be established. The new bite should not be asking muscles to work excessively at rest. The joint should not be compressed. A final new bite can be finalized by bonding porcelain to the existing teeth or often by moving the teeth orthodontically into position Or a combination of both. It can be a very conservative procedure in most cases.