At our office, we recognize that each patient is unique and no two TMJ cases are identical. Dr. Federman will comprehensively evaluate each patient’s medical history and present-day conditions to determine whether a conservative, moderate, or comprehensive treatment is appropriate for the patient. The goals of TMJ treatment are similar to those with other orthopedic and rheumatologic disorders. We know that TMDs can significantly affect a patient’s quality of life, and our long-term goals for our patients are to reduce pain, restore muscular function, and empower the patient to resume their normal daily activities.
The signs and symptoms of temporomandibular disorders may be fleeting, and sometimes resolve themselves without any treatment or long-term effects. Further studies are currently underway to determine which signs and symptoms indicate a progression towards more serious conditions. When initially treating patients with no history of prior treatment for TMDs, Dr. Federman may recommend conservative and noninvasive treatments including physical therapy, behavioral modifications, prescription medications, and the use of custom-made orthopedic and dental appliances. If a patient has suffered a traumatic injury or not responded to more conservative treatments in the past, additional options include occlusal adjustments, orthodontic treatment, and TMJ surgery.
Common causes of TMDs include bruxism (teeth grinding), adverse anatomical relationships, or facial trauma. Given the complexity of the temporomandibular joint and the unique circumstances of each patient, it is important to accurately diagnose whether the patient is truly suffering from TMJ or a different dental/orthopedic condition. During the initial examination, each relevant contribution factor will be evaluated. When it is appropriate, Dr. Federman may refer a patient to a different specialist or coordinate a treatment plan in conjunction with another practitioner with a different specialty. Fortunately, most patients with TMDs experience a significant improvement in their symptoms following conservative treatment. Below, we discuss the various options available for TMJ treatment:
Biobehavioral Therapy
Behavioral and lifestyle modifications are a crucial component of treating all cases of TMJ, regardless of their inconclusive evidence for their role in the etiology of the disorder. Success is largely dependent on patient commitment to treatment and the extent to which other factors are uncontrollable triggers for the behaviors exacerbating the symptoms of TMDs. Patients may benefit from participating in a habit-reversal program, undergoing cognitive behavioral therapy (CBT) for stress management, progressive relaxation, hypnosis, and biofeedback. Biofeedback therapy in particular may be effective because it uses equipment to measure biologic activity and contains a feedback loop so that a patient can receive immediate feedback regarding their performance. Recent studies have indicated the use of CBT in conjunction with TMJ treatment tends to be more effective than treatment alone. Each treatment plan is developed on an individualized basis based on the patient’s diagnosis and long-term goals.
Medications
Pharmaceutical medications may alleviate pain and increase patient comfort when taken in conjunction with an individualized treatment plan. Dr. Federman only prescribes drugs when he believes they may be beneficial for the patient. Given the possibility of dependency or adverse interactions, remember to only take pharmaceutical medications under the supervision of a licensed medical professional. Common pharmacologic agents include the use of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, sodium hyaluronate, benzodiazepines, muscle relaxants, antidepressants, gabapentinoids, glucosamine, chondroitin, and topical medications.
Analgesics, especially mild non-opioid analgesics, have demonstrated therapeutic side effects to treat mild to moderate pain associated with TMDs. On the contrary, opioid narcotics act on specific opioid receptors in the central nervous system. Opioid medications should be used with caution on a short-term basis given the possibility of addiction. Opioids may be prescribed to treat moderate to severe pain resulting from TMDs.
NSAIDs may be prescribed to treat inflammatory conditions as well as acute postoperative pain. Corticosteroids are only used on a limited basis based on their side effects, but in limited circumstances they may be injected to treat severe joint pain in patients who have not responded to more conservative treatments. Sodium hyaluronate may be used to support the lubricating and shock-absorbing properties of the articular cartilage.
Benzodiazepines are antianxiety medications that may be given to patients with chronic pain. Muscle relaxants may be prescribed to alleviate the symptoms of TMDs specifically resulting from increased muscle activity. Further studies need to be undertaken to understand the efficacy of muscle relaxants in treating TMDs. Antidepressants have been used in patients experiencing chronic pain for pain relief not necessarily related to depression. Glucosamine and chondritin are nutritional supplements that have been widely recognized in alleviating the symptoms of osteoarthritis and halting the progression of the disease. It is not fully understood if the pain relief resulting from glucosamine and chondritin are superior to taking ibuprofen.
Physical Therapy
Physical therapy has been proven to relieve musculoskeletal pain and restore normal function by altering sensory input, reducing inflammation, and increasing the possible range of motion. Over time, the use of therapy in conjunction with other TMJ treatments may encourage the repair and regeneration of damaged tissues. One form of therapy is posture training, where the patient is encouraged to keep the mandible in a relaxed position with the teeth separated except during function. Exercise may stretch and relax the cervical and masticatory muscles to mobilize and stabilize the temporomandibular joints. Common exercises include repetitive exercises to improve muscle function, isotonic exercises to increase the range of motion, and isometric exercises to build muscular strength.
Mobilization is another form of physical therapy involving manipulations of the patient’s joint positioning and possibly done in conjunction with heat, cold, ultrasound, or electric stimulation. Physical agents used in TMJ therapy include electrotherapy, iontophoresis, anesthetic agents, ultrasound, botulinum toxin, acupuncture, and low-level laser therapy. The effectiveness of these aforementioned methods of therapy continues to be evaluated in random clinical trials.
Orthopedic Appliance Therapy
Orthopedic appliance therapy involves the use of appliances such as interocclusal splints, orthotics, orthoses, bite guards, bite planes, night guards, and bruxism appliances. These devices are custom-made according to each patient’s dental records and TMJ condition. The primary benefits of orthopedic appliances are that they may alter the occlusal relationships and redistribute occlusal forces that contribute towards pain in the temporomandibular joint. Further clinical trials are needed to quantify whether these appliances are more effective for their functionality or as placebos instead.
Stabilization appliances cover all of the maxillary or mandibular teeth, and are often used to treat myogenous and arthrogenous TMDs. These devices are typically used during sleep only, while behavioral strategies may be used to consciously modify patient habits while awake. Partial coverage appliances may also be used, although few differences have been found in the outcomes for patients using these appliances as opposed to stabilization appliances. Anterior positioning devices may be used on the maxillary arch to guide the mandible into a protrusive position. The use of anterior positioning devices may alleviate the symptoms of TMDs by encouraging a more comfortable condyle-disc-fossa relationship and decrease joint pain, clicking, and associated secondary muscle symptoms. If anterior positioning devices are unable to move the TMJ to an orthopedically stable position in the fossa, occlusal therapy along with more permanent occlusal changes should be considered.
Occlusal Therapy
The role of occlusion in the etiology of TMDs is not well-established. However, there are many reasons for occlusal adjustment of a patient’s teeth. These include lack of inter/intra-arch tooth stability, tooth mobility, fremitus, occlusal-related fracture of a tooth or restoration, tooth sensitivity, compromised masticatory function, and compromised supporting tissues from adverse loading. Malocclusion may actually be a consequence of TMDs rather than a cause, so clinicians should not proceed with occlusal treatments until it is established through cephalometric measurements and x-rays that the patient’s temporomandibular joint is stable. Occlusal treatment alone should not be considered as the initial treatment for TMDs. In cases where specific TMD disturbances have resulted in unstable occlusal relationships, occlusal adjustment may be considered as an option to improve mandibular stability.
When major occlusal adjustments are necessary, the patient may be referred to an orthodontist for orthodontic treatment. Orthodontics may be utilized subsequent to anterior positioning appliance therapy, and often involve the use of fixed, removal, functional, and/or extraoral appliances. Clinicians should proceed cautiously before recommending orthodontic treatment for TMJ because there is always the risk of destabilizing the masticatory system during treatment. Each orthodontic treatment plan must consider possibility of occlusal instability from treating preexisting TMDs.
For patients with skeletal malocclusions or misaligned jaws, Dr. Federman may refer them to an oral surgeon for a consultation on the possibility of orthognathic surgery. Orthognathic surgery may be used in conjunction with orthodontic treatment to correct malocclusions and the positioning of the patient’s bite. Oral surgeons should always consider the stability of the maxilomandibular relationship and occlusal stability when planning for orthognathic surgery.
Surgery
TMJ surgery can be a very effective way to treat patients who have not responded to more conservative treatments. The decision whether or not to recommend surgery should depend on the level of anatomic derangement within the temporomandibular joint, the degree of impairment, and the prognosis for healing and recovery. In contrast, patients with psychologic issues or uncontrolled sleep bruxism may have a poor prognosis for TMJ surgery. According to the American Association of Oral and Maxillofacial Surgeons, TMJ surgery should only be considered when nonsurgical therapy is ineffective and should never be undertaken for asymptomatic or minimally symptomatic cases. Common surgical procedures for TMJ treatment include arthrocentesis, arthroscopy, arthrotomy, arthroplasty, and total joint replacement.
Arthrocentesis involves a simple lavage of the TMJ and can be used in patients with acute episodes of degenerative or rheumatoid arthritis and to relieve the pain from patients with clicking jaws. Arthroscopy is used primarily for minor debridement and lavage, removal of minor adhesions, and biopsies. Patients may experience pain relief from increased disc mobility following an arthroscopy. In patients with advanced TMJ diseases, the clinician may recommend an arthrotomy surgery. An arthrotomy is a more invasive open surgical procedure which involves the reshaping of the joint. Common open joint surgical procedures include discoplasty, disc repositioning, and total joint reconstruction. The success rate for disc repositioning is generally around 80% to 90%, but the high success rate for less invasive procedures in recent years has greatly reduced the need for arthroplasty.