All Posts Tagged: tmj

Use of Antibiotics for TMJ Arthritis?

Damage to the TMJ ligaments and disc results in joint sounds in most people. Clicking, popping, or grinding noises in the jaw joints (TMJ) indicates that ligaments have torn and the cartilage “disc” is being damaged and isn’t protecting the condyle. Eventually the popping and clicking “goes away” when the joint is rubbing “bone on bone” in a simple explanation.

As soon as the TMJ begins to make noise, the articular bone may start to react in one of 2 ways; the bone may develop osteoarthritis (bony spurs/thickening) as it wears down. If an inflammatory arthritis develops because the pressure is too great within the joint, the bone can rapidly disintegrate. This shows up clinically as pain in a TMJ, clicking/popping, an uneven bite, etc.

Treating TMJ with orthopedic orthotic devices (NOTR bite guards, night guards, or anterior appliances) is a critical 1st step after a thorough exam, imaging, and diagnosis. As in most orthopedic problems, placing the TMJ under a gentle but constant traction will decreases joint pressure, helps stop bone damage, and relaxes the jaw muscles.

In some cases, I utilize tetracycline antibiotics to help stabilize bone as the pressure is being relieved by oral orthotics. We can utilize some properties of the tetracycline antibiotics to help slow the bone destructive pathways as the joint pressure is being reduced with proper orthotics; similar to the effect in periodontal disease with “Periostat” after careful debridement to protect bone loss.

Doxycycline, at low doses[1] (sub-antibiotic dose) interferes with “bone resorption” pathways and can help the TMJ maintain bone and perhaps regenerate some areas that are being affected. If we catch the early signs of bone destruction in the TMJ, it’s often an effective adjunct to orthotic therapy early in treatment. I have found it especially useful in teenage patients whose bone has not reached maturity while being treated with decompression orthotics for TMJ, if this condition exists.

However, the most important thing to remember in treating TMJ conditions is that the TMJ (jaw joint/condyle) is almost 100% of the time in a posterior, compressed position when the teeth are together. This underlying, orthopedic imbalance is the root cause of almost all TMJ pathologies: clicking and popping, joint pain, limited movement, and muscle pain in the head and neck.

Use of low dose tetracycline after using an orthopedic orthotic that objectively decompresses the TMJ can be a useful adjunct to help reverse degenerative TMJ conditions.

 

 

[1] The Anti-inflammatory Properties of Tetracyclines, Weinberg, JM. Cutis. 2005 Apr;75(suppl): 6-11

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Accutane, Bruxing and TMJ

Recently, a patient presented with “clicking” that has progressed to having a locked left jaw in the morning.  They can “unlock” it easily at this point. The clicking symptoms started when they were taking Accutane for acne and the clicking seemed to resolve when Accutane was discontinued.

Did Accutane have anything to do with this?

Yes and no.  Accutane side effect profile shows that very few people who take Accutane “brux” or “grind their teeth” after 6 months of taking it (.4% of sample of 30,000 who reported it).  Bruxing seems to subside for a few months and then re-appears after another 6 months of use, but at much lower rates.  Bruxing significantly increases the pressure in the TMJ and if there is an underlying misalignment or subtle problem, it could “push it over the edge” to become symptomatic. It would have anyway…the increased pressure just hastened it’s onset.

Women report bruxing almost 3X as often as males.

The #1 reason that TMJ problems develop (regardless of bruxing) is due to the jaw joints (condyles) being “out of center in the sockets”.  This is a growth/imbalance between the upper and lower jaws that can only be seen with a 3d radiograph.  Up to 90 % of people have some “misalignment” of their TMJ, but not all develop signs (clicking, locking, limited opening or sideways movement, bite change) or symptoms (jaw pain, headaches, clenching or grinding teeth).

Many factors trigger the TMJ symptoms to appear and, once they start they don’t “go away” on their own, despite what you read and are told…the symptoms just change.

If your TMJ starts clicking, if your bite changes or feels uneven, your ability to open changes, etc…You have a TMJ problem.

It won’t “go away” on its own. The symptoms do change as the damage progresses, depending on what structures are being affected.  The sooner you can be evaluated by a credentialed dentist the better outcome you will have.  Adjusting the bite, “Equilibrating the Teeth” or using an NTI appliance or anterior bite appliance to “get the jaw in the right place” may temporarily decrease symptoms but will accelerate the orthopedic damage in your jaw.  They are the wrong devices for any type of TMJ condition and should only be used a week or so.

FDA Reports, Who have Bruxism with Accutane.

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The TMJ Treatment Debate Debunked

If you search for advice with TMJ problems, some sites suggest simple self-care is all you should do. And they say it’s a “self-limiting muscle tension problem” that will resolve.

Decades ago that might have been believed. With improved imaging technology, there is understanding of the progressive damage to the TMJ (one study showed nearly 90% of adults have a misaligned TMJ) that is asymptomatic or episodically painful or showing signs of irreversible damage, such as clicking or limited opening.

Damage to the cartilage disk inside the jaw joint begins years before signs or symptoms and is easily recognized with 3D cone beam imaging and good clinical skills. If found, it can be monitored for damage or treated before irreversible damage has occurred, if patients choose to.

A few “TMJ Advice” sites are very adamant in “not doing anything that will change the bite (or occlusion)” for a TMJ disorder. Here is the dilemma. The study mentioned earlier showed (by MRI on about 100 adults seeking braces) that most had displaced discs in one of their jaw joints.

The TMJ joint is misaligned in most of us as we grow, due to functional habits, genetics and environmental growth interferences (allergies). If your teeth aren’t ideally aligned (without braces) then YOU are one of the 90%. You may or may not develop pain, but you will have intermittent damage to the joints as the years go by. Unequal growth of the upper and lower jaws is the instigating factor.

Unequal size of the upper and lower jaw is seen as crowded or crooked teeth (even mild). Bruxing and clenching of teeth is also a symptom of this misalignment (as well as other things – stress is only a minor contributor). Over time, the cartilage, bone, or muscles may develop symptoms as damage progresses. Over several years, it becomes an obvious problem. If you can’t fit your 4 fingers between your open mouth (like a salute) you have TMJ problems, regardless of pain, at any age. Three fingers width is typically chronic degenerative disease that may have burned out and is often without acute pain. It does flare up easily with dental care.

One of the common “warnings” is to “not change the bite” if you have TMJ. Since an underlying cause of TMJ IS the imbalance of the jaws/teeth/joint, it is also the solution, if you understand current orthopedic approaches to treatment. Let’s look at options:

  1. Do nothing. Because you have been told it is “self-limiting”. As the joints/cartilage degrade or become arthritic, the lower jaw will begin to shift and cause either a noticeable bite changes or, result in bruxing, broken molar teeth, painful teeth, etc. This is the early phase. More advance damage can cause the front teeth not to touch when biting, or contribute to more teeth breaking, etc. This is a pathologic result of TMJ damage and represents a bite change. Some are dramatic. So, doing nothing WILL result in a bite change. The TMJ Association is vocal with this approach. They advocate self-help, counseling for chronic pain, and a multitude of pharmaceuticals to suppress bone damage, muscle tension, anxiety and stress, depression, etc. They are also strong advocates of psychological counseling. Their board (last time I looked) has PhD’s from pharmaceutical and psychology backgrounds. A couple dentists have received grants from them and focus on the “psychosocial” approach with some doing tooth grinding as their method of treatment (…that changes the bite… what they say NOT to do). For some cases this is appropriate but based on studies, it should be less than 10% of sufferers).
  2. Adjust the “bite” or equilibration of the teeth. Sometimes it is a minor 1-2 tooth re-shaping (due to the underlying bigger problem mentioned above) or to try and relieve muscle symptoms or joint clicking (a dislocated disc). Grinding down the teeth (and using a “bite plate” in between sessions to “relax the muscles”) is, essentially allowing the joint to degrade and grind the enamel off the teeth until the joint is so badly damaged it stops degrading or “burns out”. Often at this point the recommendation is to “crown all the teeth” because the enamel has been ground off and the teeth are flattened. The “restoration” is to restore the grooves on the teeth. What happens if the joints start degrading again? A new round of grinding the crowns and later replacing them again. I don’t support this approach as it is simply following the self-destruction of the TMJ – similar to “do nothing”.
  3. Orthopedic approach. This is what I follow and have for 30+ years. It has strong support from orthopedic literature, and organizations including the American Academy of Craniofacial pain, International College of Craniofacial Pain. The American Academy of Orofacial Pain is also embracing the orthopedic approach in recent years.
  4. The use of orthopedic orthotics (just as an orthotic can correct a leg length problem and eliminate hip/back pain) to place the damaged joint under traction, allow disc repair and re-alignment. The reflex-driven muscle tension/pain is almost always resolved. Once improved, a long-term use of a stabilizing orthotic supports the joint in a proper, comfortable position without damaging the teeth. This does result in a slight “gap” between the back teeth (due to re-alignment of the jaw from the distorted growth – the 90% of us). I recommend use of this device indefinitely or for 1-2 years to insure the condition is stable and comfortable. Some patients elect to undergo carefully guided orthodontics or crowns (if dentally indicated) that maintain the exact alignment the orthotic had, but this is the minority.
  5. Surgery. All websites and groups support that this is a “last resort” in cases when damage is so widespread from trauma, misdiagnosis, systemic disease or craniofacial syndromes. Surgical entry into the TMJ does considerable damage and always require post-surgical orthopedic therapy (# 4 above) due to the significant, post-surgical bone damage and joint destruction.

The bottom line is: You acquire a TMJ disorder because of unequal growth of the jaws. Genetics, large tonsils and/or adenoids, having a “tongue tie”, or other environmental influences on growth in the first few years of life. Correction of a TMJ disorder, will always change the alignment of the jaws and, “the bite”. If you use an orthopedic approach the “bite change”, is really a correction of abnormal jaw growth. If caught early we can use orthopedic orthodontic principles to guide growth and lessen the chance of developing a TMJ problem later.

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You, The Well-Informed Parent: Advocate for Your Children and Teens!

In my last post, it was my intention to pay attention to how your children are sleeping (or not). If YOU are awake much of the night…perhaps you need a screening for a sleep breathing disorder!

A variety of symptoms can present when children/teens don’t get the proper quantity and quality of sleep regularly. Children and teens will typically present with nighttime symptoms of bedwetting, restless sleep (kicking and banging around) or are twisted in the sheets when you go in to wake them. Hyperactivity, trouble focusing on quiet tasks, impaired growth, avoiding dry, chunky, or more difficult to swallow foods may also present.

The lack of parasympathetic sleep (restful and restorative- think “rest and digest” for parasympathetic) has an immediate and long-lasting effect if deep sleep is impaired. Early in growth it is typically the consequence of enlarged adenoids and/or tonsils. It can also be related to being “tongue tied’. This will also affect the types of foods your children will trend away from; dry foods, hard to chew foods. They may swallow without a closed lip seal or “smack” when eating. Myofunctional therapists and speech therapists trained in MFT can evaluate this condition and, once the frenum is released and airway cleared, begin to retrain the brain improper tongue positioning, speech, swallowing, etc.

If the airway isn’t cleared or isn’t developing properly due to those effects, it can be very difficult to “re-train proper swallowing or speech” until the physical barriers are dealt with.

Orthodontic treatment for under-development of the maxilla (upper jaw) may be needed to get the maxilla back towards normal size to allow the tongue and airway to properly function.

Clinical evaluation as well as radiographic of the airway, jaw growth and size, deep tonsils and adenoids and proper nasal/ maxillary growth can clearly show the physicians the medical necessity they are required to provide that “justifies” tonsil/adenoid removal.

As I tell my patients, nothing can stand in the way of a well-informed parent when advocating for their child’s wellbeing.

A list (downloadable PDF) of common signs and symptoms and visuals that parents can look for that will suggest your child or teen has an airway problem are located on our website under the Sleep Breathing Disorders tab.

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A Note From The Experts of TMJ/Craniofacial Pain

I attended the annual conference of the leading TMJ/Craniofacial pain organization this past month in which I hold a Fellowship status (AACP). After hours, I was able to spend more time with friends and mentors, often we learn as much sharing ideas and techniques as in the actual conference.

There is an increasing awareness and focus on the importance of proper nasal breathing, management of sleep disordered breathing problems such as Sleep Apnea, subtler Upper Airway Resistance Syndrome (typically in women who have poor sleep and excess fatigue without snoring or obvious apnea) and sleep breathing signs/symptoms and effects on growing children that are often missed. I am Board Certified in Dental Sleep Medicine by the American Academy of Craniofacial Dental Sleep Medicine.

Later this summer, I’ll be attending a similar conference with another organization I hold a Mastership status in (ICCMO) and look forward to spending time with those colleagues, many of which are the same experts.

I look forward to expanding my knowledge base, clinical tips and techniques, and comparing notes with my friends who are also leaders in the field of TMJ and Dental Sleep Medicine.

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No Pain, No Problem?

 

Is asymptomatic the same as “normal” and is “No pain, No problem” the standard of TMJ care today?

Many chronic conditions such as hypertension, diabetes, heart disease, arthritis and neck problems go on for years without pain or notable symptoms by patients. TMJ dysfunction is also a progressive, measurable problem that ultimately leads to muscle or joint pain, bite issues, tooth fracture and loss, headaches, ear pain, dizziness, among other head and neck symptoms.

In medicine, it has become standard to consider chronic, measurable joint damage as “normal” only because it isn’t painful. There are many reasons this has come to be the norm and is accepted. Early intervention is better than almost all attempts to manage advanced bone and joint disease, especially the TMJ.

We know that infants that have short lingual frenum’s (tongue tied) don’t nurse well, have more problems eating as teeth erupt, and have altered jaw growth. Likewise, early allergies to foods and environmental triggers can enlarge the tonsil tissue in the nose and throat. This leads to a cascade of growth distortions throughout the maxilla, mandible, and TMJ that strongly influence the onset of TMJ misalignment, damage and dysfunction over time.

Crooked teeth are the initial sign (not symptom) that growth has been negatively affected. Straightening the teeth with braces may or may not correct an underlying TMJ problem. Sometimes the TMJ becomes symptomatic as orthodontics begins to move teeth that have an unstable jaw joint. Over our life, the adaptive systems change in response to direct injury, growth disturbances, and small or large injuries throughout the body. This is adaptation. As our adaptive capacities change over time, the compensation may be exceeded and pain or altered movement becomes noticed. One respected TMJ author (McNeill) estimates that 75% of the population may experience signs of TMJ/masticatory problems.

A  study this year (2018) assessed the Temporomandibular Joints (TMJ’s ) of 186 randomly selected people between ages of 18-21 that had no symptoms of a TMJ problem or an obvious bite problem found upon closer evaluation that 33.4% of the TMJ’s examined had early stretching/damage to the TMJ ligaments. 8% showed incomplete disc displacement and 5% had discs that fully displaced. None had symptoms based on current dental misconceptions of TMJ dysfunction.[1]

The earlier children are screened by a TMJ expert the better the opportunity to guide growth through non-surgical orthotic treatment as they progress through orthodontics or as a general risk assessment as they approach the teenage years. This can help avoid more complex damage to the TMJ, and less effective therapy if intercepted earlier and growth is redirected back towards heath of the jaws and TMJ together.

 

[1] Assessment of the Temporomandibular Joint Function in young adults without complaints from the masticatory system: International Journal of Medical Sciences, 2018;15(2). Kondrat, Sierpinska, Radke.

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Aggressive TMJ Arthritis in Teenage Girls – Juvenile Idiopathic Arthritis

Over the past few years, I have seen a growing number of young women and girls with aggressive, degenerative arthritis in their TMJ joints. They didn’t have pain until the damage was late, usually a couple years after clicking started in their joint. Clicking in a TMJ means that the cartilage disc has torn off of the bone and no longer cushions the joint. Arthritis will start soon after. Typically it is wear and tear arthritis, but more recently I’ve seen the aggressive arthritis as mentioned in this study.

The study results align with my experience and more specifically targets juvenile idiopathic arthritis and its underdiagnoses. As the article reports, the TMJ diagnosis is often late because it’s rarely painful in the first 1-2 years.

The two hallmark signs that should prompt an evaluation are limited mouth opening (normal for all ages is the width of 4 fingers between the front teeth – or above 40-44mm open) and clicking in the jaw joint. Either sign should prompt a clinical and radiographic evaluation by an experienced TMJ specialist to assess for early signs of the degenerative joint disease.

The study recommends that to prevent lifelong orofacial complications, early recognition and treatment is important. The signs or symptoms in teenage and early adult females are changes in the bite, TMJ clicking or popping and/or pain in the TMJ area. Young girls seem to be more likely to have this condition, but males are also affected.

A clinical exam of the TMJ along with our high resolution, low dose i-cat 3-D imaging can show the early signs of degernative joint disease and clinical limitations that are associated with it. Decompressing the TMJ with orthotics is one of the most important interventions to arrest the disease. Additionally we would refer for JIA (juvenile idiopathic arthritis) testing in the event other joints might be at risk.

J Oral facial Pain Headache 2017;31:165

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TMJ and Scuba Diving

TMJ & Scuba Diving

Over the years I’ve seen a few patients whose TMJ symptoms started while scuba diving. Some had been diving for a longer time, while other patients it occurred on their first open water dive.

A recent article [1] surveyed divers regarding dental pain and reported barodontalgia (tooth ache from ambient pressure change) in 42% of divers, Pain from holding the regulator too tight in 24% and TMJ pain in 22%. I would suggest that the pain from holding too tight might refer to TMJ muscle or joint referred pain. It didn’t differentiate that pain. It also reported 22% specific pain in the TMJ. Potentially the 2 categories would suggest that TMJ or TMJ muscle pain occurs around 50% of the time in scuba divers of all levels.

Clenching tight on a mouthpiece can induce a lot of sustained pressure in the TMJ. No joint is designed for long term loading. If someone clenches while diving for an hour or so, it will compress most of the lubricating fluid from the TMJ disc (this is called exhaustion of weeping lubrication).

This creates areas on the disc that stick to the bony socket and upon moving the jaw, the disc itself can tear or it can tear the ligaments. This will typically cause a sharp pain and then feel like the joint is swollen. If the disc ligaments are damaged, the TMJ disc can slip and begin to click or the jaw may lock and not be able to move well.

If your bite feels off after scuba diving, it can be from a muscle cramp. The best thing is to let the jaw slowly re-align over 20-30 minutes. Don’t try to bite hard to get the teeth to touch. Avoid any heavy chewing until the bite returns to normal. Attempting to clench and get your teeth to touch could damage the joint irreversibly.

If the bite doesn’t get back to normal, have your TMJ evaluated by someone specializing in TMJ disorders to determine the nature of the problem and give you options to correct it. Adjusting the bite (occlusion) wouldn’t be the first line of treatment, but might be considered later.

[1] Dental Abstracts; Nov-Dec 2017, V62: Dental Pain When Diving

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Waking the Dead (and grumpy): Teenagers and Sleep

Why is it that getting our teenagers up and going is sometimes such a battle?

We nag them to get up, they want to sleep longer

We’re in a hurry- they can’t seem to get out of bed

They stay up too late…

Actually, it’s not totally their fault.  As kids enter teenage years their circadian rhythm, as well as the rest of their physiology, begins to change. All parents know that for sure! Teens are known for staying up late and sleeping in. During teenage years, melatonin’s release (the sleep hormone) is delayed. Teenagers start getting sleepy (melatonin release) around 11pm and need more time to fall asleep.  8-10 hours of sleep is ideal for teens according to the American Academy of Sleep Medicine. They need to sleep until around 7:30 AM.

There is a growing pressure on school systems to change school start times based on research in the sleep literature. It’s being met with resistance because of our work schedules, after school programs/sports and parent’s time schedules. It’s a clash between physiology and a society that has, for decades been on a schedule that seems to have trended earlier over the decades.

According to an article in this month’s American Academy of Sleep Medicine journal:

Short sleep in adolescents is associated with poor school performance, obesity, metabolic dysfunction and cardiovascular morbidity, increased depressive symptoms, suicidal ideation, risk-taking behaviors, athletic injuries, and increased motor vehicle accident risk.917 Increased motor vehicle accident risk is particularly concerning because young, novice drivers have a higher crash risk when sleep deprived, and motor vehicle crashes account for 35% of all deaths and 73% of deaths from unintentional injury in teenagers.1820

Importantly, a delay in school start time has beneficial impacts on teenage students. Studies show that implementation of later school start times for adolescents is associated with longer total sleep time, reduced daytime sleepiness, increased engagement in classroom activities, and reduced first-hour tardiness and absences.7,2123 Delayed school start times also are associated with reduced depressive symptoms and irritability.21,22 Reaction time improves, and crash rates decline by 16.5%, following a school start time delay of 60 minutes.12,13 Extension of sleep time also facilitates behavioral weight loss interventions in adolescents.24.

There isn’t an easy solution to this clash between physiology and society’s needs. But recognizing it can take some of the stress off families. Let the kids schedule relax on the weekends for sleep, talk to them about “sleepy driving” and remaining alert. Perhaps a nap after school would help some of them. If they seem overly tired, they should be screened by a qualified Dentist in sleep/breathing disorders for airway obstructions and altered craniofacial growth that may be a contributing factor.

Read more about sleep disorders in kids here. 

Citation: Watson NF, Martin JL, Wise MS, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Olson EJ, Ramar K, Rosen IM, Rowley JA, Weaver TE, Chervin RD. Delaying middle school and high school start times promotes student health and performance: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13(4):623–625.

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A Good Night’s Sleep

Walking through the airport I saw a cover of Consumer Reports regarding how to sleep better.

It reviewed all types of mattresses, pillows, sleep positions, etc. suggesting that this is the primary cause of poor sleep. Not most likely.

While discomfort in your neck, back, or hips can disturb your sleep, the PRIMARY cause of sleep issues in America today is BREATHING. You’re not breathing well. Sleep Apnea, Upper Airway Resistance, Reactive Airway conditions are the most likely culprits robbing you of restful, restorative sleep.

If you have neck, back, shoulder or spinal disease or pain, the pressure and position you sleep in can cause progressive pressure on discs and nerves as you sleep. As you enter deeper stages of sleep your joints may become “irritated” enough to cause a signal to the brain to move or change positions to lessen the pressure. If it happens often enough you will feel that you’re not sleeping well. These are the conditions that pillows and mattresses can improve.

Most sleep disturbances in adults result from Obstructive Sleep Apnea, Snoring, or other conditions involving airway collapse during sleep. If you snore, there’s a near 70% chance that you have Sleep Apnea or that your oxygen is dropping to levels that increase risk of stroke or heart attacks. That is the first consideration to rule out.

Narrowing of the throat (such as with snoring, gasping, jerking) is a reaction to significant drops in the oxygen in your blood and brain. The brain reacts by sending a “flight or fight-like” surge of adrenaline to jerk or twitch us awake and take a breath (but not awake enough to remember) This can happen many time per hour and rob our body of sleep it needs to be mentally sharp.

Another stage of sleep causes all body muscles to be “paralyzed” and completely relaxed. This is believed to be so that our joints, vertebral discs, and cartilage discs, ligaments can have time to repair and heal from the day’s jarring. The oxygen drops associated with Sleep Apnea episodes (snorts, snoring, gasps) are micro-arousals (mentioned above) that re-engage the muscles and interrupt the joint repair periods of sleep. This can lead to joint discomfort, muscle aches and pains, etc. in the morning. Especially if we already have some “wear and tear” on our joints from sports or activities.

If you suffer from poor sleep, achy tired joints in the neck, back or TMJ in the morning, make sure to have your Physician or a Dental Sleep Specialist evaluate you for potential Sleep breathing problems, in addition to finding comfort with pillows and mattresses.

Our website has a convenient, private self-assessment that you can take and have instant feedback as to risk factors for  a Sleep breathing disorder. TMJ problems are also associated almost 70% of the time to a sleep disorder. Clenching and bruxing are also activities triggered by breathing interruptions that eventually damage the joints and discs, in addition to our teeth.

I work with local Sleep Specialists and Physicians to help determine whether patients with TMJ pain, neck pain, or other symptoms should be screened for a sleep disorder.

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