TMJ/TMD Temporomandibular Joint Pathology

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

The temporomandibular joint (TMJ) is a complex joint shaped like an S, and a fibrocartilaginous disc divides the joint into two cavities. The joint actually joins three separate structures, the mandible with the mandibular fossa, and the mandible with the temporal tubercle, making this a complex joint compared to all others in the body. The mandible is the jawbone, and of course, is used a lot, both for eating and speaking, so pathology of this joint can be a nagging constant irritation, even without overt pain. The real health concern involves much more than this joint problem, though, as the TMJ has been recognized as just the tip of the iceberg. Problems with TMJ are now recognized as a health disorder (TMD) and this disorder involves much more than a simple joint misalignment, involving neurological dysfunction, sleep disorder, and implications affecting cardiovascular health, hypertension, fibromyalgia, and other chronic health problems. Relegating TMD treatment to dentists and mouth devices has been a big mistake with enormous implications for public health.

Problems with the TMJ can become severe and episodic, and a number of contributing factors can irritate the joint, especially myofascial syndromes, with neuromuscular factors contributing to worsening symptoms. The relatively mild overt symptoms in most cases of developing TMJ pathology, or TMD (temporamandibular disorder), cause us to overlook the serious underlying health problems that can be caused by, or are the cause of TMJ disorder, but these may be the most important concerns.

"TMJ" is a term that has been given in the last 30 years to a medical syndrome that is increasing in frequency as a health problem and now proven to be associated with a number of other difficult health problems, including sleep apnea, migraine headache, tension headache, tinnitus, nocturnal bruxism, chronic neck and back pain, and even depression and anxiety disorders. This musculoskeletal and neuro-orthopedic pathology was first called Costen's Syndrome, and then Temporomandibular Pain and Dysfunction Syndrome (TMPD), for many years, until the medical field relegated it to a dental concern and just called it "TMJ". Finally, with more patients demanding medical attention due to nagging problems with this chronic disorder, and more patient awareness of the scope of their syndrome, research has demonstrated how a comprehensive holistic treatment protocol is necessary to correct this neuromuscular condition. In chronic cases the underlying and associated health problems, such as nocturnal bruxism and neuropathy need to be addressed, and often, related problems such as poor sleep quality and mood disorder need to addressed as well. The Licensed Acupuncturist and herbalist with skills in myofascial release is the ideal physician to manage this type of care.

Pathology of the TMJ is referred to as a TMD, or a Temporomandibular Disorder. To show you how lightly standard medicine treats this common health problem with serious long-term consequences, we still have not given it a real medical name, and continue to just call it TMJ. A wealth of research on this problem has been driven not by public health concerns, but by new expensive technology and treatment, and finally standard medicine is referring to the problem as TJS, or temporomandibular joint syndrome, expressing the fact that the problem is not so simple, and may include quite the variation and complexity of associated health problems within a syndrome. It is conservatively estimated now that over 11 million U.S. citizens have a temporomandibular joint syndrome of some severity, and over 35 million suffer from some TMJ problems.

Experts in the field now prefer to call these TMJ problems Craniomandibular Disorders, and some would expand the diagnostic terminology to Trigeminal Mandibular Disorders to describe the fact that the fifth cranial nerve (CN5) is involved in this pathology, and the elusive origin of the problem may actually lie in a neuropathy of this combined sensory and motor facial nerve. This more accurately describes the focus of dysfunction in the pathology, namely, the dysfunction of the medial pterygoid muscle, which unlike the other muscles of mastication, is innervated not by the facial nerve (CN7), but by the trigeminal. The term Trigeminal Mandibular Disorder (also termed TMD) elucidates this key aspect of the TMJ disorder and syndrome. While the treatment in this disorder or syndrome needs to be individualized and sometimes comprehensive to fully cure, myofascial release of the medial pterygoid muscle is most important in the protocol.

The medial pterygoid muscle is not the only muscle involved in this neuromuscular disorder, though. Muscles of the temple as well as muscles of the neck can also add strain to the joint. While the medical establishment has pushed theories of dental problems and inherited joint abnormalities in recent years, the truthful conclusion is that TMJ is a multifactorial problem that requires treatment of a variety of muscles as well as reeducation of the patient to avoid habitual aggravation of the TMJ. For some patients, underlying health problems should also be addressed. To see a recent synopsis of scientific findings in the New York Times, click here: http://www.nytimes.com/2009/02/03/health/03brod.html?_r=1&ref=health. While the headline implies that nothing can be done for TMJ, careful reading of the article shows that it is oral and maxofacial surgery that should be avoided, and that a treatment protocol of intelligently applied physiotherapies and stress management, which should include acupuncture, is the preferred course.

A comprehensive approach to TMJ pathology includes myofascial release of the local muscles, or pterygoids, as well as the release of the scalenes and neck extensors, and possibly the temporalis. In addition, stress reduction, instruction in postural mechanics and targeted stretch of the TMJ, and assessment of the joint inflammation and potential contributors and cures should be included. Acupuncture, herbal medicine, and nutriceutical aids to tissue health and nerve function can all contribute to overall success of treatment. Individually, no one specific treatment approach has given proof of great success, but combining all of these therapies, each having shown limited success in treatment, adds up to a cumulative protocol that guarantees a successful outcome.

Standard medicine has also adopted a holistic and comprehensive protocol to treat TMJ now, utilizing soft tissue mobilization with electrical stimulation, ultrasound, heat and cold therapies, active release techniques, and joint manipulation to restore myofascial function and clear tissue toxins and irritants. A small number of specialized clinics now offer this treatment protocol in hospitals and clinics. Description of this protocol, which is very similar to the TCM protocol, and may be integrated with TCM, acupuncture, physiotherapy, postural correction and herbal/nutrient therapy, can be seen at this website: http://www.tinnitusformula.com/infocenter/articles/conditions/tmj.aspx

The many health problems found to be associated with TMJ disorders

A variety of health problems are associated with TMJ disorders. Tinnitus is a persistent and often complex pathology that is associated with TMJ in a percentage of patients. If the mechanical irritation of TMJ is one of the causes of this persistent symptom, relief of TMJ may be a very important part of the treatment protocol to finally reduce or eliminate tinnitus. TMJ is also associated with sleep apnea, and may be an important factor in this multifactorial syndrome as well, which is primarily caused by tissue hypertrophy in the nasopharyngeal area. Biomarkers for TMJ include vascular endotherlial growth factor (VEGF) that is also seen in excess in hypertrophied tissues of the mouth and throat in sleep apnea. Nocturnal bruxism, or grinding of the teeth, a tardive dyskinesia that apparently is stimulated when the patient is in deep sleep, and does not smoothly transition from the first or second stage of deep, or REM, sleep, is also associated with TMJ pathology. This nightly grinding of the teeth may not only cause dental fractures, but irritate the scalene muscles, which play a role in mastication. A vicious cycle may evolve in this case. Both the myofascial syndromes, which eventually result in a denervated supersensitivity, and the central nervous system dyskinesia of bruxism, potentially contribute to autonomic nervous dysfunction. TMJ is also indirectly associated with Raynaud's Syndrome, a vasospastic autonomic nervous disorder, in which the extremities may be triggered into a state of sudden loss of circulation with cold and purplish coloring, and often pain. The involvement of the scalenes in TMJ disorders and concurrently in thoracic outlet syndrome (TOS), as well as the eventual autonomic stress, link TMJ potentially to TOS and Raynaud's Phenomenon, another poorly understood, but common and annoying pathology. Various problems that are associated may need to be resolved together to effect a sufficient cure. To gain a more thorough understanding of tinnitus and sleep apnea you may go to the articles devoted to these conditions on this website.

Of course, various types of headache are associated with TMJ pathology as well, as well as chronic neck, upper back, and even shoulder pain. The problematic muscles that contribute to TMJ disorder may also be causing tension headaches, referred myofascial pain, and affecting the mobility of the cervical spine. Migraine headaches, which are now recognized as a disorder frequently driven by temporal ateritis, or inflammatory problems affecting the ateries in the temple, is also associated with TMJ disorder, or TMD, because these temporal arteries travel alongside the trigeminal nerve and are innervated with offshoots of this cranial nerve. Dizziness and ear problems have also been found to be associated with TMJ in some instances, and here too, an anatomical relationship between the trigeminal nerve and arteries explains how this is possible. A thorough and intelligent assessment should be performed to evaluate relationships between these problems, and assess the whole health history to see if underlying health problems are potentially contributing. In standard medicine this could mean trips to a number of specialists, a variety of expensive tests, and elaborate specialty clinics that just address one aspect of the whole problem. With holistic medicine, and a Licensed Acupuncturist with a number of therapeutic skills, these problems may be addressed together and more directly. Integrating the holistic perspective and the various practical treatment modalities of Traditional Chinese Medicine is a smart choice.

More recent studies have also found a potential relationship between TMJ disorders and related health problems and increased incidence of depression and anxiety disorders. Since chronic TMJ may be caused by myofascial syndromes that eventually cause autonomic dyfunction, as well as sleep disturbance and bruxism, a plausible relationship between TMJ disorders and neurological dysfunction and stress is not out of the question. Of course, relieving TMJ will not cause these various other serious health problems to instantly disappear, but it may be a key part of the overall treatment and help resolve other serious health problems down the road.

The Trouble With Current Approaches to Treatment of Temporomandibular Disorder

Temporal mandibular joint disorders relegated to the dental profession, with the common use of cone-beam computed tomography to diagnose, despite the risks of accumulated radiation, and the lack of training in musculoskeletal medicine for a musculoskeletal and neuromuscular health problem

NOTE: The leading experts in the musculoskeletal disorders in the last few decades, Drs. Janet Travell M.D and David Simons M.D., state in their definitive text, Myofascial Pain and Dysfunction that: "Historically the dental profession has considered occlusal disharmony and variation as a potentially primary etiologic factor in TM disorders. However, literature reviews and data from recent studies do not support occlusion as a significant etiologic component of TM disorders." (Magnusson et al; Orafacial Pain 8:207-15;1994)(Pullinger et al; Oral Surg Oral Med Oral Pathology 71;529-34;1991)(Pullinger AG; J Dent Res 72;968-979;1993)(Verdonck et al;J Oral Rehabil 21;687-97,1994). Further scientific studies since 1994 confirm these findings and reveal the multifactorial causative etiology in TMJ disorders. Still, for lack of appropriate treatment protocol in standard medicine, the dental profession has hit upon this pathology as a new area of treatment promotion in dentistry, and the insurance industry has promoted this approach, despite decades of scientific study citing the inappropriateness of a dental or oral surgery approach to this musculoskeletal, not dental, problem.

While oral occlusion, or the misalignment of the upper and lower jaw during use of the jaw, or mandibular action, does occur due to TMJ disorder, this misalignment in almost all cases is due to contracture of the medial pterygoid and other muscles of the jaw and neck. This occlusion is not the cause of the problem in TMD in almost all cases, and an allopathic realignment does not resolve the underlying causative problems of TMD. Because there is no practical treatment plan for TMD in standard medicine, or for pain complaints in TMD, and because there is a strong resistance to integrate Complementary physiotherapies and a holistic approach, the standard treatment for this health problem is now a dental device, which was intended to protect the teeth from the wear and tear of nocturnal grinding, not to correct the disorder. Appropriate holistic treatment with myofascial release, neuromuscular reeducation, and acupuncture will resolve this myofascial dysfunction that may lead to a joint arthropathy, and if needed, the problems with joint arthritis, as well as the neuromuscular pathology in many cases, addressing both the symptoms and the underlying causes. The only reason for insurers to deny coverage for treatment of TMJ disorders from the appropriate treating physicians, utilizing a comprehensive approach and integrative multidisciplinary diagnostic assessment, is that it costs less to let the profession of dentistry treat this pathology, and the industry bias against CIM (Complementary and Integrative Medicine) is still strong. Considering the number of serious health problems proven to be associated with TMJ disorders, though, this is not even a medical cost saving strategy in the long run.

TMJ therapy is now described as dentistry's "hottest" area of business, heavily promoted in dental colleges, and promoted by both the insurance and medical equipment industries. Today, many prominent dentistry experts are warning that most of the testing protocols and treatments routinely prescribed for TMJ disorders by dentists are not supported by scientific studies of medical efficacy, create negative long-term consequences, and sometimes come with considerable risks down the road. Dental surgeons are also promoting orofacial surgery in many cases, despite the poor outcomes and risks present in surgical correction of TMJ disorders. Dr. Joseph Marbach, an expert in the diagnosis and treatment of chronic jaw and facial pain, a professor at the University of Medicine and Dentistry in New Jersey, the late director of a facial pain clinic at Harvard, and a prominent researcher at the University's School of Public Health, stated that surgical options for correction of TMJ disorders should not be considered. Despite such expert advice, the dental industry is heavily promoting surgical correction, and the public is led to believe that any dental surgery is different and more benign than surgery performed by a MD surgical specialist.

Use of the cone CT to analyze TMD comes with considerable risk. Patients should also be aware that a particular dentist should present the proper credentials of dental specialty when using a cone CT to diagnose TMD occlusion and treating with medical devices or oral surgery. These credentials would indicate a more than two year advanced training after completing a standard dental degree, and include Orthodontics (diagnosis and correction facial deformities), Oral Pathology (diagnosis of diseases of the head and neck), Oral and Maxillofacial Surgery (diagnosis and surgical treatment of diseases and defects of the jaw), and Oral and Maxillofacial Radiology (expertise in safely performing advanced radiological diagnostic tests and interpreting them).

The X-ray and CT diagnostics in dentistry are often described as harmless tests that you shouldn't worry about. The fact is that these tests need to be performed expertly and with the right equipment and settings to minimize harm and risk. Many dentists performing radiological testing with cone-beam computed tomography have no advanced training in radiology, and the tissue injuries from these procedures, which involve focused arrays of high-speed X-ray slices (typically 60 to 300 X-ray slices in a single CT), sometimes appear weeks after the CT testing, when the test was not performed properly. The safety of these CT devices are promoted by the manufacturers, and insufficiently regulated by health authorities. Dentists with older X-ray equipment may also be using outdated equipment with excessive radiation, and many dentists are taught to take these radiation exposure problems lightly. A good dentist will only use radiology when absolutely necessary, not just to sell the dental work. Since radiology is a complex medical specialty, the patient population that thinks that anyone with little or no training can expertly interpret even simple X-ray films is naive. Long ago, we assumed that X-rays were harmless, but with decades of data, we now know that they aren't.

The percentage of cancers directly attributed to CT scans in the United States quadrupled between the late 1990s and 2007, with government estimates that up to 2% of all cancers in the United States may be directly attributed to CT scans with the dramatic increase in their use. Low level radiation is accumulative, and while these accumulations are not as serious as radioactive isotopes with long half-lifes, there are now so many sources of man-made low level radiation in the United States that an alarming number of cancers are not attributed to radiation. The 2009 Annual Report by the President's Cancer Panel stated that nearly half of American's radiation exposure now comes from medical imaging, compared to only 18% 30 years ago, and warned that this dramatic rise in radioactive testing now is a predominant cause of radiation induced cancer, and a significant contributor to most cancers, which have a multifactorial cause. Radiation, which to some extent is normal in our natural environment, has always been considered the primary cause of cancer, but the cavalier use of radiological testing, despite the development of other benign forms of testing, such as advanced portable MRI and ultrasound, presents an unnecessary cancer risk that the public should be aware of and refuse unless it is absolutely necessary to diagnose a health problem.

The widespread use of "night guards" in the treatment of TMJ disorders also have come with misinformation and health risks, and are not supported by sound scientific studies. While modest benefit has been proven in some small studies, the evident risks and potential long-term harm revealed in these studies should prompt patients to more closely consider the benefit-risk ratio, and utilize these devices for short term relief of symptoms while pursuing more effective comprehensive and holistic therapy. Most of these devices are not the same as simple mouth devices used to prevent teeth grinding injury from nocturnal bruxism, but instead are mandibular orthopedic repositioning appliances (MORAs) that require proper fitting from a dentist with advanced training. These occlusal devices have been shown to be nonspecific in their action, and modest benefits from properly fitted MORAs are derived from mild decrease in muscle fatique when excess nighttime teeth grinding, or bruxism, is present. They do not resolve the essential myofascial dysfunctions, arthritic degeneration, or neuromuscular problems. When worn too much, these MORAs can affect the proper position of the teeth at the base, eventually causing pain or discomfort, and sometimes requiring orthodontic or surgical correction later in life. Despite the long-term possible negative consequences, many dentists without advanced specialist training are fitting these oral devices to supposedly correct TMJ problems. The prescription of more benign night guards whenever there is a report of jaw clicking or grinding is also unwarranted, and in some cases, these devices, which cover all the teeth to prevent wearing down of tooth enamel, may irritate actual TMJ disorders. While these night guards are proven to not cause teeth to become misaligned, they may increase myofascial strain in some patients, and should only be prescribed when tooth enamel wear is an obvious problem, and not overprescribed whenever a patient reports nocturnal grinding and benign jaw clicking. Patients with TMJ disorders and nocturnal bruxism should seek a comprehensive treatment to resolve these health problems instead of just relying on night guards and excessive use of MORAs to reduce symptoms.

Obviously, TMJ disorders are not a simple dental problem, but rather, dental problems occur due to TMJ disorders. It is a big mistake to relegate TMJ disorders, considering the complexity of this pathology, to dentistry. Many insurance plans will not pay for treatment and diagnostic workup of TMJ disorders outside of a dental plan. This is unbelievably ridiculous. Patients are often shunted to dentists, who have little or no training in musculoskeletal medicine and neurological health, and the standard guidelines now are pushing many unnecessary specialized CT scans of the mouth.

A series of article in 2010 in the New York Times (cited below with easy links) explains the dangers and harm from all of this excess radiation in medicine. Simple physical exam diagnoses TMJ disorders, and exposing onself to multiple X-rays in cone-beam CT is preposterous. Many patients are led to believe that since these tests are conducted in a dental office, that they must be benign. This is far from the truth. The truth is, that many medical experts around the world are now calling for the industry to give up radiation in testing almost entirely. With new technology, this old technique of imaging is no longer necessary, especially as we are now exposed to numerous sources of environmental radiation. Radiation, even at a low dose, is accumulative in most cases, and exceeding an accumulative level is more than our bodies can handle in repair of cellular mutations. Hence, we get cancer. It appears that only when the public shows awareness of these risks of X-ray and CT that the medical device industry will actually utilize the technological know-how that they already possess to create testing devices that cause no harm. The only reason that this industry has not done this is due to the question of profits, and public health regulation may need to step in if the public does not demand a positive change.

Now, many experts associated with the growing industry of advanced radiological testing tell us that they can find hardly any cases of direct causing of cancer or tissue injury by these procedures. Obviously, since radiation is ubiquitous in the natural environment, and causes an accumulative effect, a single low-dose radiation exposure cannot be blamed by itself for a specific cancer in most cases. The same argument was given for atomic bomb tests, leaking nuclear wastes, radioactive water dumped into rivers from power plants, radioactive material in armaments, and even nuclear power plant meltdowns in the past. Does the public never learn? Are we such fools? Anyway, this just diverts a patient from the real issue, which is that a physician with training in musculoskeletal medicine can easily diagnose TMJ disorders, and a comprehensive package of care can address all of the factors in this multifactorial disorder. The options presented in dentistry should address only dental problems, and the intelligent patient will seek effective medical care from physicians skilled and knowledgeable in musculoskeletal medicine. This is not to say that every Licensed Acupuncturist has these skills and is knowledgeable. Choose wisely. Most acupuncturist can deliver modestly effective needle stimulation in the overall treatment protocol, but for many patients with a TMJ disorder, a more comprehensive package of care is necessary, with myofascial release of the ptyerygoids and scalenes included, as well as effective joint mobilization and neuromuscular reeducation. For individual cases, concurrent treatment of related health problems should also be performed.

A variety of TMJ disorders are seen under the umbrella of Craniomandibular Disorders and Trigeminal Mandibular Disorder, and a full assessment of the problem helps to guide therapy more successfully

The U.S. national TMJ Association finds that TMJ disorders may be divided basically into three categories: arthritic, joint derangement, and myofascial pain syndromes. A fourth category, neuromuscular disorders, is still under investigation, and will be somewhat controversial until more research is conducted. Proper assessment and integration of conservative therapies is all-important.

Arthritic TMJ disorders are often associated with osteoarthritic degeneration, Rheumatoid Arthritis, or some other form of rheumatic arthritis that typically affects the jaw, such as Polymyalgia Rheumatica, which has seen an explosive growth in incidence, and is associated with the autoimmune disease Giant Cell Arteritis. Giant Cell Arteritis is seen in 15% of patients with Polymyalgia Rheumatica, and primarily affects the temporomandibular joint. Joint derangement, such as subluxation or disc degeneration, usually occurs due to an imbalance of stress on the joints from the muscles of mastication. Myofascial pain syndromes involve a muscle firing dysfunction with a syndrome of dysfunction and generation of referred pain. You may learn more about myofascial pain syndromes, rheumatic, or autoimmune disorders, and arthritis on other articles of this website. Another cause to consider is the number of cases of jaw degeneration due to the side effects of biphosphonate drugs, which are used to treat osteoporosis, bone pain in cancer therapy, or in cancer therapy related to estrogen receptor stimulated cancers. FDA warnings have been issued concerning the eventual degeneration of the jawbone, and increased gum infections, loose teeth, numb heavy sensation in the jaw, and increased tooth and gum pain are signs of the degeneration, or osteonecrosis, associated with use of biphosphonate drugs. While cases of severe jaw osteonecrosis are still relatively rare with these drugs, it is believed now that milder degenerative changes are very common.

Osteoarthritis of the cervical spine, a degenerative condition primarily related to poor postural and mechanical habits, may also play a considerable part in the causative etiology of TMJ disorders. When the normal lordotic curve and mobility of the midcervical spine is decreased, abnormal pressures and stress are increased to the various structures that primarily cause TMJ dysfunction, such as the neck extensors (esp the splenius cervicis), the scalenes (attached to the midcervical vertebrae), and the cranial nerves and blood vessels. In these cases, therapy to resolve the cervical osteoarthritic arthrosis should be performed.

The vast majority of TMJ disorders are primarily due to myofascial pain syndrome though, usually involving the pterygoids and scalenes. The temporal muscles, although thin, can also contribute in many cases, especially when chronically tight neck extensors, or splenii muscles, generate frequent tension headaches. The splenius cervicis, or extensor muscle attached to the cervical spine, affects the temporal muscle in cases of tension headache that are felt along the side of the head to the posterior eye orbit. In these cases, joint derangement may eventually occur due to the myofascial syndromes and imbalances of muscular stresses on the complex joint of the jaw during eating and talking. It is important to properly assess each individual case for evidence of these other conditions, though, which would alter the therapuetic protocol. A combination of myofascial release and passive joint mobilization is central to the therapeutic protocol in most cases of TMJ disorder involving myofascial syndromes and joint derangement as the primary cause or manifestation. Knowledgeable professional assessment and individualized and comprehensive approach is obviously important in the treatment of TMJ disorders. For too long, we have taken this syndrome or complex disorder too lightly.

Complementary and Integrative Medicine in the Treatment Protocol for TMD

By 2015, many experts in university medical schools and institutions have recognized that standard treatment protocols and diagnostic assessment for TMD (temporomandibular disorder) has been woefully inadequate, and that these disorders often imply a problem with underlying health problems that should no longer be ignored. There is no evidence that the standard multi-drug pharmaceutical protocol has worked, with an unhealthy combination of NSAIDS, corticosteroids, muscle relaxants, anti-anxiety and anti-depressive drugs often prescribed as the pain symptoms gradually become worse and worse. There is also very little evidence supporting the use of dental medicine as the main treatment option, and many reasons to discourage widespread use of botulinum toxin (Botox) and corrective surgery. Finally, there is a number of authorities recommending the integration of acupuncture into the treatment protocol, and an array of studies validating this treatment efficacy (see study links below in Additional Information).

While standard acupuncture is useful to address pain and neuromuscular pathology, TCM (Traditional Chinese Medicine) offers an array of potential therapies that make this treatment much more effective. Particular providers with proper training in medical school may combine acupuncture, trigger point needling, soft tissue mobilization (Tui na), myofascial release and neuromuscular reeducation, as well as spend the time to help instruct patients into therapeutic techniques and correction of postural mechanics used outside the clinic. In addition, if there are underlying or associated problems perpetuating and worsening the TMD, these may also be addressed in the same course of therapy.

Patient education in neuromuscular control and kinetic habits may be an effective part of a comprehensive protocol to cure or relieve TMJ disorders

An effective treatment protocol for TMJ disorders needs a strong proactive participation by the patient. The patient needs to correct the problems that caused, and are perpetuating, the specific TMJ disorder. A knowledgeable physician is able to assess and point these out to the patient, so that postural correction, stress reduction, and neuromuscular reeducation can be accomplished. The physician is always there to help the patient resolve health problems. The intelligent patient realizes their responsibility to understand and resolve the health problems themselves, with the help of the physicians and therapists.

The most important considerations in resolving TMJ disorders are forward head and neck postures, excessive use of the jaw (e.g. chewing gum, frequent snacking on chewy foods, excessive talking, or habitual movements) especially with postural stress during jaw movement, a slumped shoulder posture, and correct tongue position. The tongue should relax with the tip against the roof of the mouth just behind the upper teeth, but not quite touching the teeth, and most breathing should be through the nose in relaxed states, or in through the nose and out through the mouth, with the lips slightly parted. An exercise to restore neutral tongue position at rest: correct the head and neck posture, say the work Boston and let the tongue end up against the upper palate after enunciating the "N", hum the letter N for a few seconds, and exhale with a relaxed sigh. Try to maintain the tongue position with the tongue tip against the roof of the mouth just behind, but not touching the upper teeth, while in a relaxed state. Many patients with TMJ disorders acquire bad mechanical habits that perpetuate the pathology and go unnoticed. A relaxed posture during meals, rather than eating on the go, may be helpful, unconscious chewing on one side of the mouth may be occurring, perhaps due to tooth and gum irritation, and should be acknowledged. Stess response may be habitual, such as clenching the teeth, and can be resolved with proper conscious attention.

While strength exercises of the masticatory muscles are almost never warranted in TMD patients, because the muscles are constantly working, some neuromuscular reeducation could be very helpful. Experts in the past, such as Schwartz and Bertoft, have recommended a protocol of reflex relaxations of the pterygoids. These neuromuscular exercises can irritate the deranged joint, though, and proper instruction should be utilized to perform them correctly, or the neuromuscular reeducation should be performed with physician guidance. Slow opening of the jaw fully with lateral movement, first in one direction, and then in the other, with resistance applied during slow closing of the jaw is the standard technique. These exercises are best performed after the muscles are released, though, as the usual neuromuscular problem is overfunction, and not underfunction, meaning that the pterygoids and other masticatory muscles, such as the scalenes, are in constant firing mode, rather than insufficient firing. If the muscles are not relaxed before neuromuscular reeducation, stretch movements and resistance may irritate the contracted muscles and tendons. Over time, though, with myofascial syndrome, the muscles are not only continually firing into contracture, but become weak due to this constant neurostimulation. Concurrent contracture and weakness, or a combination of overfunction and underfunction, is what perpetuates TMJ disorders. If attempting to perform neuromuscular retraining without physician guidance, some gentle finger tapping and circular massage are suggested as a relaxing warmup.

Stretch is a patient activity that may both help resolve myofascial trigger points in the elevator muscles of the temporomandibular joint and accomplish some neuromuscular reeducation at the same time. Therapeutic stretch should always be targeted, slow and conducted with a patient approach. Fast hard stretch may be applicable to athletic training, but has no place in therapy. By applying the mind, and focused attention, to the targeted tissues, a neuromuscular retraining may be accomplished. Therapeutic stretch of the jaw is always recommended in TMJ disorders, but should not be overdone. Therapeutic targeted stretch of the neck muscles should also be taught to the patient, and this should be performed daily.

Sleep posture may be very important to the resolution of TMJ disorders. Sleeping face down should be avoided and corrected completely. If this is a problem, lying face down when going to bed for a few minutes, until you are feeling very sleepy, may be allowed, and then turning to a side posture with the neck properly supported at the level of the spine, and the shoulder not tucked under the body or the hand under the head, is the best sleep posture. Neck support is best accomplished with a feather pillow, Japanese quality buckwheat hull pillow, or a Tempurpedic foam (which doesn't jiggle in REM). If the scalenes ar excessively tight at night, a small riser under the legs of head of the bed may tilt the bed just enough to take some pressure off with gravity, but not enough to be noticed. Furniture floor protectors may be thick enough, or a small can stuffed with cloth may be used provide a stable riser with enough height. If the bed is on a hardwood floor with a rug under the legs of the foot of the bed only, or the house is tilted, your bed may be actually tilted slightly with the head below the feet, aggravating the neck muscles with excess tilt stress during the night.

If the patient is spending a lot of time driving, driving posture and stress can be very causative or perpetuating of TMJ disorders. Avoiding driver stress, teeth clenching, excessive talking or singing while driving with postural stress, eating while driving, and excessive turning of the head all may be important factors. A forward head and neck posture during driving should be corrected. Some helpful routines may be to use a low back supporting pillow to help sit more upright, adjusting the car seat so that you are in a more balanced upright position, using the pelvis to stabilize instead of muscles, and trying to move the feet and legs without using upper back and neck muscles. When you are at a stoplight, take a few seconds and deep breathe, and push the head gently against the neck brace cushion to flatten the cervical thoracic joint, tucking the chin to the chest, and then exhale with a sigh. Shift in the car seat occasionally, and stop and take a short walk after an hour in the car on long drives. All of these may may a difference in neck and jaw tension.

Another type of neuromuscular reeducation that may be helpful is patient focus on proper TMJ movements during jaw opening. By placing the index and middle fingers, or the heel of the hand, against the temporomandibular joint, and the other index finger against the chin just below the mouth, the patient can practice repeatedly, for a few minutes per day, the proper motion of the joint. This should be performed sitting, and the tongue pushed against the hard palate, with slow opening of the jaw within a non-painful range, and a slight push against the chin to prevent excess jaw protrusion. Some resistance may be needed against the temporomandibular joint or the jaw if abnormal movements of lateral joint rolling or jaw protrusion are noticed. Strong pressure should be avoided, though, as this could cause joint irritation. Slow, focused jaw movement is the key to neuromuscular retraining, not forceful pressure. Maintaining the pressure with the tongue against the hard palate, or roof of the mouth, prevents one type of unnatural jaw movement that often irritates the TMJ. Taking a deep breath during the jaw opening, and a relaxing outbreath, or sigh, during the closing phase, also neuromuscularly helps with reflexive retraining.

A technique that may be useful, but in some cases may cause irritation to the joint when self-administered, is bilateral pressure applied at the TMJ with the heels of the palms while slowly opening and closing the mouth fully in a non-painful range of motion, and feeling the movements of the TM joints to try to achieve as smooth of a motion as possible. This technique may be best employed while lying supine, or face up, to decrease active tension on the jaw. This simple procedure allows the patient to focus control of the jaw movement more effectively, and may carry over into unconscious neuromuscular control during eating and talking. Patients who must talk a lot at work, such as those on the phone most of the day, may be particularly helped by neuromuscular reeducation. Of course, better ergonomic habits should also be learned in these cases. Use of headsets, or attached ear phones, are highly recommended. Eliminating the cradling of the phone against the shoulder is absolutely necessary, and better body mechanics in holding the phone and insuring that unnecessary neck rotations are not performed while talking are also very important. Use the chair swivel and your feet to turn when talking on the phone, as well as the gaze of the eyes instead of turning of the neck while talking are habits that should be reinforced. This type of concurrent use of the scalene neck muscles during activities of the jaw, with turning of the head and forward head and neck posture, can be the source of the injury. Of course, professional guidance on targeted ergonomic, or body mechanics, retraining are most effective. Simply changing the workstation does not really address the problems created with ergonomics, though. The term ergonomics actually means body mechanics, and does not mean furniture design.

Another type of kinetic neuromuscular retraining may be accomplished either with the aid of the physician, or at home by the patient alone. By placing the end of the little finger in the ear and presssing on the end of the mandible, or lower jaw, the movement, or lack of, is very evident. Gentle pressure on this part of the bone while engaging in slow and relaxed opening and closing of the mouth, with reflexive activities of breathing and eye movements to aid contraction and relaxation, may be very helpful to reengage the joint with proper relaxed normal movements. Start by placing the tip of the little finger in the ear and gently pressing on the end of the mandible. By opening and closing the mouth, the mandibular movements will become obvious on the tip of the finger. Once the finger is in place, open the mouth as far as is comfortable and relax. Maintain gentle pressure on the mandible while taking a deep breath and looking up, at the same time slowing closing the jaw. When the jaw is closed, maintain gentle pressure, breathe out with a a sigh, and look down. See if the joint can relax into a less tight alignment. Repeat this exercise a few times.

Lastly, many people that work and talk with stress do not breathe diaphragmatically. Each seventh breath is usually a deep diaphragmatic breath. When one is stressed at work and talking, the avoidance of this necessary breathing reflex occurs, and this can contribute a lot to TMJ disorders. The scalene muscles are both masticatory and deep inspiration muscles, and stabilize the neck during active movements. Both diaphragmatic muscles and scalenes may eventually become held in contracture and contribute to improper breathing habits and improper active jaw movements, as well as inhibition of normal cervical range of motion. Nerve impingement, even the irritation of the trigeminal nerve, may occur. Release of these various muscles with myofascial release techniques and trigger point needling may be a key to therapy, but also patient reeducation to normal diaphragmatic breathing with a conscious control, may be very helpful. Patients with allergies and/or asthma, or even simple nasal congestions, are more prone to these problems. By taking a few minutes each day and practicing nasodiaphragmatic breathing, either lying supine or sitting, can be very helpful in the therapeutic protocol. Diaphragmatic breathing is accomplished by sitting upright and balanced, relaxing the shoulders and jutting out the sternum, and breathing consciously and slowly, first expanding the belly, or the muscles below the diaphragm, and then proceeding slowly to inflate the entire chest to the upper rib cage. Hold the full breath for one second and then let the air escape from the mouth in a sigh to reflexively relax the diaphragm. Other techniques touted include placing a soft ball (such as a tennis ball) against the thoracic spine at the level of the lower scapula while performing this breathing reeducation, and keeping the tongue held against the roof of the mouth.

Understanding various symptoms in TMJ disorders and their cause

Clicking of the jaw is caused by the impact of the articular disc complex against the most protruding portion of the upper joint, the eminence. This requires that the disc is moved, with tight jaw movement, forward and medial, as the lower bone of the jaw moves over the eminence to allow the fullest opening of the mouth. With clicking, the lower jawbone, or condyle, must override a too thick portion of the central disc, and then pop into a thinner disc portion. This implies that the disc may be unhealthy, and/or that the medical pterygoid muscle is pulling the mandible, or lower jawbone, medially out of place during jaw opening. If left untreated, this will usually progress toward a jaw locking as it opens, which is quickly resolved, and patients often just get used to this click and lock. Pain comes later. To resolve, the medical pterygoid should be functionally restored with myofascial release, and if this is insufficient, trigger point needling with the jaw propped wide open. Manual release is usually painful, or at least uncomfortable, but is rewarding, and if done properly, will resolve medial and main pyerygoid muscle contracture with just 1-3 treatments. If this is not sufficient to fully release the muscle, a trigger point needling is used, but this approach is difficult until the pterygoid is released, and the jaw is able to open wide enough for the needle position. The patient that may be deficient in ascorbic acid (Vit C) should take a high dose before treatment to facilitate the trigger point releases.

A crunching or rough sound sensed by the patient with jaw movment is most likely creptitus, or the sound of mineral deposits and calcifications in the joint capsule and disc complex. If there is a pathology of disc and capsule degeneration in this complex joint, the full resolution may take some time, as these tissues are avascular. Just as in the degeneration of discs in the cervical and lumbar spine, disc rehydration depends upon some decrease in tension on the disc. Lacking a direct vascular supply, the disc and other joint soft tissues depend upon the relief of muscular contracture and the gentle motions of the joint to rehydrate. If the disc is hardened, either due to arthritic calcification, inflammatory scarring or hypertrophy, or dryness, steps should be taken to resolve these conditions. Sensations of stiffness and swelling may be explained by these problems. Increased circulation, decreased mechanical stresses, herbal formulas to decrease excess inflammatory cytokines and growth factors noted as markers of TMJ pathology (TNFalpha and VEGF especially), and perhaps hyaluronic acid if dry tissues and cells are suspected, all may be combined in a holistic protocol to treat the causes of stiffness and swelling. Expert passive joint mobilization (Tui na in Traditional Chinese Medicine) is essential to clearing mineral deposition in these tissues, but must be combined with a thorough holistic protocol.

Many of the cases of TMJ disorder, or TMD, may not involve pain, or involve pain that comes and goes. If there is pain, an underlying joint inflammation, or arthritis, should be suspected. This type of pain is typically described as an aching pain around the joint, with an occasional spasm of sharp pain and jaw immobility. Three types of pain scenario, or explanation, are presented by Drs. Janet Travell and David Simons, in their definitive text on myofascial disorders. These are 1) true mandibular joint pain, 2) myofascial pain due to trigger points alone, and 3) myofascial pain that is perpetuated by a noninflammatory or intermittently inflammatory joint condition. Treatment should be tailored individually to reflect these considerations. A physician that understands the myofasical syndrome and referred trigger point pain patterns is able to assess this pain properly.

Information Resources / Additional Information and Links to Scientific Studies

  1. A 2010 analysis of over 1500 patient with TMJ disorders at the Medical College of Wisconsin Department of Population Health found that TMJ disorders represent quite an array of complex pathophysiologies and clinical manifestations associated with a number of chronic comorbidities, and predominantly affect females between the ages of 30 and 50: http://www.ncbi.nlm.nih.gov/pubmed/21178593
  2. A comprehensive analysis of TMJD (temporomandibular joint disorder) is found at the TMJ Association: http://docs.google.com/viewer
  3. A 2010 article on standard treatment for TMD (temporamandibular disorder) by experts at the University of British Columbia School of Pharmacy, stated that numerous studies show that the level of pain seen in many temporamandibular disorders does not correlate with the level of actual tissue pathology, implying that the disorder in these cases of TMD pain is multifactorial and involves the facial nerves, the CNS, psychosocial factors and neurohormonal imbalance. This university school of pharmacy states that while 90 percent of treatment recommendations for this pain involve use of a variety of medications, NSAIDS, corticosteroids, muscle relaxants, anxiolytics, opiates, and tricyclic antidepressants, "evidence in support of the effectiveness of these drugs is lacking": http://www.ncbi.nlm.nih.gov/pubmed/20337865
  4. A 2001 study sponsored by the U.S. National Institutes of Health (NIH) in Bethesda, Maryland, revealed that Temporomandibular Disorders (TMD) were strongly implicated in cardiovascular disease and sleep disorders, including the complex array of sleep breathing disorders that are rarely diagnosed and treated properly: http://www.nhlbi.nih.gov/files/docs/workshops/tmj_wksp.pdf
  5. Although extensive research into the proof of acupuncture outcomes with TMJ disorders is yet to come, small studies in Europe have shown consistent improvement in randomized clinical trials. In a real clinical setting, the acupuncture would be just one part of the treatment protocol: http://www.ncbi.nlm.nih.gov/pubmed/16645291?dopt=Abstract
  6. A 2016 systematic review of all scientific studies concerning temporomandibular disorder (TMD) and otologic signs and symptoms, or problems related to ear and hearing disorders, recognized that acupuncture is now considered part of the standard conservative treatment protocol for TMD, along with mouth devices, counseling, biofeedback and exercise. There was still insufficient evidence regarding the effects on ear and hearing disorders, and a recommendation that more studies be conducted of conservative therapies: http://www.ncbi.nlm.nih.gov/pubmed/26749516
  7. A 2015 meta-review of all studies of manual physiotherapies to treat temporomandibular disorders, by the Federal University of Sao Carlos, in Sao Carlos, Brazil, and Salamanca University, in Spain, concluded that evidence strongly supports manual physiotherapies, but the results vary widely according to the treatment techniques. Myofascial release, deep tissue massage, and joint mobilization were found to be as effective as control treatments such as Botox. Of course, study design, with comparative control placebo treatments, blinded to the patients, is very problematic, and serves to diminish the quality of manual physiotherapy that can be used, yet despite these drawbacks, numerous studies still confirmed efficacy with evidence. All of these manual physiotherapies can be obtained in TCM treatment if the physician is trained in Tuina, the soft tissue mobilization techniques of Traditional Chinese Medicine, and combined with effective acupuncture, herbal and nutrient medicine: http://www.ncbi.nlm.nih.gov/pubmed/26059857
  8. A 2015 study at the University of Sao Paolo and University of Campinas Schools of Dentistry, in Brazil, showed that a short course of acupuncture reduced pain intensity and sensitivity in TMD and should be considered part of the treatment strategy for chronic pain related to TMD: http://www.ncbi.nlm.nih.gov/pubmed/26276455
  9. In 2010, a clinical report concerning treatment of TMJ disorders with subluxation at the University of Pennsylvania, physicians found that for most patients, addition of a simple acupuncture regimen increased the success of joint manipulation dramatically: http://www.ncbi.nlm.nih.gov/pubmed/21319604
  10. A 2010 meta-analysis of scientific studies of acupuncture in the treatment of TMJ disorders, by the University Europea of Madrid, Spain, shows that acupuncture is a reasonable and effective part of a holistic treatment protocol in standard medicine: http://www.ncbi.nlm.nih.gov/pubmed/20551730
  11. A 2013 clinical study and assessment of appropriate treatment for TMD and tinnitus, by the University of Gottenburg and University of Bergen, in Sweden and Norway, concluded that many patients could benefit from integration of acupuncture into care with the intraoral splint, or occlusal device: http://www.ncbi.nlm.nih.gov/pubmed/24341163
  12. A 2010 study of myofascial trigger point needling, termed dry needling, at the University Ray Juan Carlos, in Spain, found that this trigger point needling into the masseter muscle trigger points (TrPs) resulted in significant improvement in function compare to sham needling. The experienced Licensed Acupuncturist is the ideal physician to successfully needle myofascial trigger points, which may be combined with other acupuncture techniques, manual myofascial release, and neuromuscular reeducation in the same treatment session: http://www.ncbi.nlm.nih.gov/pubmed/20213036
  13. A 2010 meta-analysis of scientific studies of acupuncture in the treatment of TMJ disorders, at Kyung Hee University Medical Center in Korea also found that systematic review found that acupuncture showed moderate evidence as an effective treatment intervention for TMJ disorders: http://www.ncbi.nlm.nih.gov/pubmed/20401353
  14. A 2009 study at Sao Paolo University in Brazil, found that acupuncture treatment resulted in sustained beneficial changes in a 3-month follow-up study, with improved neuromuscular activity (EMG studies), increased strength of masticatory muscles, and sustained remission of TMJ pain: http://www.ncbi.nlm.nih.gov/pubmed/19958104
  15. A 2008 study at the University of Arizona in Tucson, found that a treatment system that utilized a number of treatment options with Traditional Chinese Medicine and Naturopathic Medicine resulted in significantly greater reduction of pain, and psychosocial interference, than standard medical protocols: http://www.ncbi.nlm.nih.gov/pubmed/18564953
  16. A 2009 randomized controlled human clinical trial of a common topical herbal ointment to treat TMD pain showed that this Ping On ointment significantly reduced pain and increased function. Various topical herbal ointments and creams could prove valuable as part of a holistic therapy, presenting a safe, effective and healthy treatment tool: http://www.ncbi.nlm.nih.gov/pubmed/20001836
  17. A 2015 study at the University Nove de Julho and the State University of Campinas, in Brazil, found a strong correlation between diurnal cortisol levels and intensity of TMJ or TMD disorders. Such research points to the need for a more holistic approach to treatment and restoration of neurohormonal homeostasis. TCM/CIM presents such an approach to treatment: http://www.ncbi.nlm.nih.gov/pubmed/25995595
  18. A study at Missouri State University found that polyphenols in grape seed extract, (also found in whole pomegranate extract and some Chinese herbs), may be a beneficial addition to the treatment protocol for TMJ disorders, resolving problems in the trigeminal nerve associated with TMJ pathology: http://www.ncbi.nlm.nih.gov/pubmed/21143976
  19. A 2005 study at Wakayama Medical University in Japan found that serotonin receptors in the trigeminal nerve near the upper cervical spinal cord are involved in mediating both proprioceptive and nociceptive effects in TMJ syndrome, suggesting that perhaps use of a serotonin aid, such as 5HTP, may be beneficial in the treatment protocol. A combination of 5HTP, melatonin (which is a potent antioxidant and neurotransmitter), P5P, and St. John's Wort extract could significantly benefit therapy: http://www.ncbi.nlm.nih.gov/pubmed/16112478
  20. A 2000 randomized controlled study at the University of Hong Kong found that a Chinese herbal ointment, Ping On, significantly reduced TMJ pain symptoms compared to placebo, and improved the ability to fully open the jaws: http://www.ncbi.nlm.nih.gov/pubmed/20001836
  21. A 2010 meta-analysis of studies of the use of mouthguards, or intraoral appliances now routinely prescribed to relieve TMJ disorders show modest benefit but potential for adverse events and irritation, and stabilization appliances should be used that are professionally adjusted, and used with monitoring and caution: http://www.ncbi.nlm.nih.gov/pubmed/20664825
  22. A warning by a prominent dental surgeon concerning the heavily promoted dental diagnostics and treatments for TMJ disorders is presented here: http:/www.dentalwatch.org/questionable/tmj.html
  23. A survey of medical and dental students with TMJ disorders found a variety of associations of other health problems prevalent with persons with TMJ: http://www.ncbi.nlm.nih.gov/pubmed/21206936
  24. Demographic health studies in Brazil found a significant relationship between TMJ disorders and migraines, episodice tension headaches, and chronic daily headaches: http://www.ncbi.nlm.nih.gov/pubmed/19751369
  25. A review of scientific studies, meta-analysis, and systematic reviews in clinical research found significant incidence of TMJ disorders following whiplash injury in motor vehicle accidents. Whiplash injury primarily involves a myofascial strain syndrome of the neck extensors and stabilizers, namely the splenii and scalene muscle sets. This analysis also finds an association with traumatic stress and TMJ disorders: http://www.ncbi.nlm.nih.gov/pubmed/21206925
  26. A 2011 study at Daemen College in Amherst New York found that two biomarkers, an endothelial growth factor (VEGF) and D6 (a heptahelical membrane protein expressed by lymphatic endothelial cells, and associated with specific inflammatory cytokines) were associated with TMJ, potentially linking the underlying pathological processes to other disorders with these biomarkers: http://www.ncbi.nlm.nih.gov/pubmed/21163381
  27. A 2011 review of modern dental training shows that computed tomography, a form radiological testing that uses a large number of quick X-rays, is now pushed as standard dental practice, much of it to diagnose TMJ. The public must start expressing some alarm to reverse such trends: http://www.ncbi.nlm.nih.gov/pubmed/21205734
  28. A 2010 article in the New York Times shows that some radiological experts at major universities are concerned about the pushing of unnecessary dental X-rays and cone-beam CT scans: http://www.nytimes.com/2010/11/23/us/23scanbox.html
  29. A 2010 article in the New York Times expresses the natural alarm at the pushing of cone-beam CT scans in dental offices and the unbelievable misinformation that is so cavalierly distributed to medical and dental personel to sell them on these scans: http://www.nytimes.com/2010/11/23/us/23scan.html