Neuromuscular Dentistry

Clicking or Grating sounds in the Jaw Joint

A normal, healthy Temporo Mandibular joint is quiet during function. The jaw movements are smooth without any pulling to one side (called Deviation) or abrupt changes in speed and direction (called Deflections). The glenoid fossa (the socket, which is part of the Temporal bone that also houses the ear hole, hearing mechanism and the balancing organ) is connected to the condyle (the rounded head of the Mandible that articulates with the fossa) by ligaments that bind the two bones together.

There is a cartilaginous disc between the two bones to act as a bearing. This disc has no blood supply and so is nourished by the slick synovial fluid which aids in the smooth movement. The back of the disc is tethered to the back of the joint with a soft band of retro-discal tissue that has blood and nerve supply. The front part of the disc is connected to a small muscle (called Lateral Pterygoid muscle) that pulls it forward during opening of the jaw. The discal ligaments hold the disc tied down to the head of the condyle.

If there is trauma (either acutely from a blow or chronically from clenching) to the discal ligament that leads to a tear, then the disc would slip out from between the two bones. This dislocation is usually Anterior (to the front). As the jaw is opened to a certain amount, the tether holding it to the back of the joint makes the disc jump on to the top of the condyle - where it belongs. This leads to a clicking or popping noise.

In rare cases, the disc would stay in front of the condyle and so would not allow the jaw to be opened very far. Such a condition is called a closed lock of the TM Joint.

But as the jaw closes, the disc slips out - usually without much noise. So the joint now has the soft retro-discal tissue between the bones instead of the disc. Since this tissue has blood supply, it can lead to inflammation. If this tissue is perforated, then there is bone to bone contact during function. The joint surfaces get rough leading to a grinding noise. Arthritis of the TM Joint can lead to destruction of the bony surfaces.

It is easier to tolerate and minimize the use of other joints in the body afflicted by arthritis. But the TM Joints are in use every time we eat, speak and swallow 2000 to 3000 times a day. So arthritis of TM Joints really impacts the quality of one's life.

A clicking and popping TM Joint may lead to irreversible damage to the joints. It is best to correct them at an earlier stage than later.

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Ear Symptoms

Tinnitus

Ringing and roaring noise in the ears may be from several causes. Loud noise, clogging of the external auditory canal with ear wax, inflammation of the ear drum, over dose of medications such as Aspirin are all possible sources of tinnitus. But a large number of cases are due to TMD.

Tinnitus arises from the traction on the malleus by Pinto's ligament (disco-malleolar ligament) and/orassociated musculature to the ear and Eustachian tube (tensor tympani and tensor veli palatini from throat) as wellas other triggersparticularly medial Pterygoid muscle. These triggersmust be released.

Tensor tympani is a tiny middle ear muscle that is attached to the malleus. When contracted, the tension is increased on the tympanic membrane. Its nerve supply is from the Mandibular nerve, a branch of the Trigeminal Nerve (fifth Cranial Nerve).

Pinto’s ligament connects the articular disc of the TM Joint to the malleus bone of the ear.

Ear Pain

When the ear aches inside, most patients conclude that it is an ear infection and go see their primary physician or ENT specialist. If an otoscopic examination is normal, the source of the ear pain could be TMD. As discussed above the muscles that are associated with the ear are mostly controlled by the Trigeminal nerve. Poor alignment of the jaw can lead to spasm of any of these muscles leading to “ear pain”. So instead of prescribing an antibiotic as a shot gun treatment for this phantom ear infection, a TMD evaluation is appropriate.

While the Eighth cranial nerve enables hearing, one of the sensory branches of the Fifth cranial nerve – Trigeminal innervates the middle ear leading to the referred pain.

Another way TMD gives rise to ear pain is due to the remnants of Pinto’s ligaments that connected the posterior portion of the glenoid fossa (the socket of the TM Joint) to the middle ear. In TMD, the condylar head is often posteriorized – pushed backwards - leading to increased pressure in this area causing ear pain.

Stuffiness of the ear / Ear congestion

The Eustachian tube is a membrane lined tube that connects the middle ear space to the back of the nose. Its primary function is to ventilate the middle ear, ensuring that the pressure inside the ear remains at near normal ambient air pressure. The secondary function of the Eustachian tube is to drain any accumulated secretions, infection, or debris from the middle ear space. Several small muscles located in the back of the throat and palate, control the opening and closing of the tube. Swallowing and yawning cause contraction of these muscles, and help to regulate Eustachian tube function. If it were not for the Eustachian tube, the middle ear cavity would be an isolated air pocket inside the head that would be vulnerable to every change in air pressure and lead to an unhealthy ear.

Normally, the Eustachian tube is closed which helps prevent the inadvertent contamination of the middle ear by the normal secretions found in the back of the nose. A tube that is always open is called a patulous Eustachian tube. Patients with this rare condition are plagued by chronic ear infections. A much more common problem is a failure of the Eustachian tube to regulate pressure effectively. Partial or complete blockage of the Eustachian tube can cause popping, clicking, and ear fullness.

As Eustachian tube function worsens, air pressure in the middle ear falls, and the ear feels full and sounds are muffled. Eventually, a vacuum is created which can then cause fluid to be drawn into the middle ear space (termed serous otitis media) If the fluid becomes infected, the common ear infection (supperative otitis media) develops.

Ears can feel stuffy and congested when the Eustachian tube is blocked. This can happen with swelling and inflammation as when there is an infection. It can also happen when the tiny muscle that controls the opening – called Tensor veli palatini is in spasm. When the jaw alignment is poor, the muscles of mastication and associated posture muscles have to compensate. This constant compensation can lead to muscles spasms and trigger points. By neuromuscularly correcting the jaw relation often leads to the resolution of the various symptoms…including ear symptoms from this cause.

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Neuromuscular Treatments

A diagnosis of TMJ/TMD means you have a dysfunction in the jaw joint and jaw muscle areas. Your neuromuscular dentist will study the relationship between your teeth, jaw muscles,and your jaw movements, to understand the dysfunction and formulate a strategy for improvement. Treatment may involve repositioning the jaw into its most comfortable posture and supporting it with an oral appliance. Once comfort is attained, more permanent support is attained through Orthodontics or restorative procedures.

Each individual has unique jaw joint dysfunction, and a combination of therapies may be recommended for permanent correction. The goal of treatment is to alleviate pain, soreness and other symptoms and to improve the function of the jaw joint.

Treatments for TMJ/TMD may include:

• TENS electrical stimulation
• EMG measurements of Facial Muscles
• Cosmetic Dentistry
• Oral appliances
• Medication
• Physical therapy
• Lifestyle recommendations

TMD Diagnosis

Treating TMD is no easy task. The nerves, muscles, joints, teeth and supporting oral structures must all be thoroughly evaluated for an individual diagnosis of the cause of your TMD, and to determine the best course of treatment.

Fortunately, advances in dental technology now allow Dr. Kelly to more accurately measure and determine your most comfortable jaw position, and to outline a customized course of treatment to achieve your goal of pain relief.

The TMD Examination

Our evaluation begins with your comprehensive medical and dental history.

Other features of the initial evaluation include:

• Radiographic examination (X-rays) or Cat scan
• Muscle palpation
• Posture analysis
• Photographs
• Computerized technology

State-of-the-art dental technology plays an important part in your TMD diagnosis. Dr. Kelly offers the very latest technology for a fast, accurate and thorough diagnosis, including:

Sonography

Sonography accurately measures joint sounds as you open and close your mouth to diagnose the precise degree of clicking, popping, grinding and grating occurring in the joint.These sounds are analyzed for sound frequency, allowing Dr. Kelly to fully evaluate your level of joint and ligament damage.

Electromyography

An electromyograph measures electrical activity in the chewing muscles to determine how the muscles function when working and at rest. An EMG verifies the measurements for the most comfortable new position of your jaws

Computerized Jaw Tracking

The computer and the Sensoray accurately measure jaw function in three dimensions and helps to position your teeth for the most comfortable jaw and joint positions.

TENS – Transcutaneous Electrical Neuromuscular Stimulation

The MyoMonitor is an ultra low frequency TENS unit that delivers a mild electrical impulse to the muscles. This positively affects the muscles with relaxation, increases blood flow, and removes toxins, to coax muscles back to their most comfortable length and position.

Symptoms of TMJ/TMD may include but are not limited to:

Head and face problems:

• Headaches and migraines
• Neck pain
• Jaw pain and soreness
• Jaw or neck stiffness
• Facial pain
• Forehead pain
• Cluster headaches
• Sinus-like headaches
• Scalp tenderness
• Mouth, face, cheek, or chin pain
• Dizziness or vertigo
• Tongue pain

Tooth and gum problems:

• Premature tooth wear
• Tooth loss
• Teeth clenching
• Teeth grinding
• Tooth pain
• Tooth sensitivity

Jaw problems:

• Limited opening of the jaw
• Locking of the jaw
• Clicking or popping of the jaw joints
• Uneven alignment of upper and lower teeth when jaw is closed
• Uncontrollable jaw movement

Ear problems:

• Ringing in the ears
• Hissing or buzzing in the ears
• Clogged ears
• Hearing problems
• Ear pain or soreness

Eye problems:

• Pain
• Blurred vision
• Bloodshot eyes
• Increased eye pressure
• Light sensitivity
• Watery eyes

Throat problems:

• Swallowing problems
• Tightness in the throat
• Sore throat
• Voice fluctuations
• Laryngitis

Other problems:

• Neck or shoulder pain
• Back pain
• Tingling or numbness in the arms or hands

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TMJ pain

TMJ stands for Temporo Mandibular Joint. This is the joint in front of the ear hole, that connects the mandible (lower jaw) to the temporal bone of the cranium. The temporal bone houses the hearing and balance apparatus as well. 

Pain at the TM joints is usually due to an inflammation of the ligaments that hold the two bones - temporal and mandibular bones - together and form a capsule around the joint. This Capsulitis is in turn due to strain in the joint from clenching or grinding very hard in deep sleep. The underlying cause of this is the disharmony of the bite - a malocclusion. 

The other causes of pain in TM joints are due to internal derangement - a torn ligament that acts as the tether for the articular disc between the two bones. The disc is meant to act as a bearing between the articular surfaces of the bones when they function. When the disc is dislocated, at some point during opening of the jaw the disc will pop in to place causing the clicking noise. 

When this dislocation is uncorrected, it could lead to destruction of the joint surfaces and result in arthritis of the joint. This too would be a source of TMJ pain.

Healthy TM joint. Quiet joints smooth movements

Dislocated disc causing popping/clicking noise.

Damaged joint causing grinding noise.

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What exactly is Sleep Disorder Breathing?

The most common Sleep Breathing Disorder is related to obstruction of airway. It is a continuum with varying degrees of blockage of airway. On the milder end of the spectrum is snoring. If the obstruction is partial, there is vibration of the soft palate that constitutes the noise of snoring. If the blockage leads to a mild (less than 4%) drop in blood oxygen level it is termed a Hypopnea. RERA (Respiratory Effort Related Arousal) is the phenomenon of struggling for breath that disturbs the sleep. Complete stopping of breathing of over 10 seconds with effort to breath and leading to more than 4% drop in blood oxygen level is Obstructive Sleep Apnea (OSA). The frequency of events per hour determine if OSA is mild, moderate or severe (over 30 events per hour).

Sleep apnea is a public health issue that is more prominent than diabetes. It is estimated that 50 million Americans suffer from this disorder.

Obstructive sleep apnea (OSA) is associated with snoring, daytime drowsiness, obesity, and other risk factors. Patients with OSA are at increased risk for:

• High blood pressure
• Irregular heart beats
• Heart attacks
• Stroke
• Decreased libido
• Impotence
• Gastro Esophageal Reflux Disease (GERD)
• Heartburn
• Morning headaches
• Dry mouth
• Irritability
• Impaired concentration
• Depression

The best way to diagnose Sleep Disordered Breathing (that includes Sleep Apnea) is a Polysomnogram (Sleep Study). Allexcept Severe Sleep Apnea and Central Sleep Apnea are best treated with oral appliances. They are easier to get accustomed to and easy to take with you when you travel.

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TMJ / TMD Frequently-Asked Questions

What are the most important symptoms I should be concerned about?
Pain, and/or jaw locking episodes.
What is a locking episode?

A "locking" episode can occur during opening or closing movement. What happens is that the patient experiences an interruption of jaw movement - a "catch" or a "stop", and in order to complete the movement must jiggle, or somehow, self manipulate the jaw.

Why does it happen?

Referring back to my anatomy lesson, and in the simplest of terms, what is happening within the Joint is that the Articular Disk which rides on top of the Condyle Head is getting stuck in the wrong place and is preventing the Condyle Head from moving.

If I can jiggle my jaw and reduce the dislocation, why should I be concerned?

Because each time it happens more damage is occurring to the tissues in the Joint, and the tissues controlling the Articular Disk. As a consequence there is the risk that if the problem is not addressed by appropriate treatment, one day you will be unable to reduce the dislocation yourself, and you will require an emergency visit to a TMJ practitioner, if one is available in your community, or an oral surgeon. In severe cases, reduction can only be accomplished under general anesthesia.

What is a limited range of opening?

If you open your mouth as wide as you can, and then place the last three fingers of your hand (middle, ring, and pinky) perpendicularly (with your thumb pointing to the ceiling) between your upper and lower teeth, you have a normal range of opening, provided that you can do that without pain and strain. In general, two fingers, or less, is a limited range of opening.

I can get four fingers in. What does that mean?

Not much. You may either have thin fingers, or you have slight hyper-extension. In the absence of pain, and other symptoms, not to worry.

I can only get two fingers in. Does that mean I need treatment?

Here comes a typical doctor's answer - "that depends". It depends on several factors. The most important being, to what degree is this restricted jaw function affecting your quality of life. If you have no pain, and it is the ONLY symptom you have, and you never think about it, and you can eat anything you want without pain and strain. The answer is no. Otherwise the answer is yes.

I hear a lot of noises in my TM Joints when I move my jaws. Sometimes there is a kind of click, and sometimes there is a crunching or grinding sound. What's happening?

Probably, lots of things. Joint noises during jaw movements are a sign that the functional elements are not working smoothly. Crunching grinding noises are called Crepitus, and it is associated with hard tissue contact during movement. In order to explain Clicking, you have to first know that the Articular Disk has, what is most simply described as, a depression, in the middle of it. That depression, and the Condyle Head are supposed to move together in sync. When they don't, and the Condyle Head passes over the outside ridge of the depression, you get a click.

Is the presence of these Joint sounds serious?

Again, in the absence of other symptoms, no. BUT, these Joint sounds are a sign that the Joint is not functioning smoothly, and each sound's occurrence is a micro trauma to the Joint tissues. This means that as time goes on, a full blown TM Joint disorder may develop. The correct approach, if you have TM Joint sounds during jaw movements in the absence of all other symptoms, is to tell your Dentist about them, and he will keep your condition under observation.

Why are ear symptoms associated with TM Joint disorders?

Because of the close proximity of the ear tissues to the TM Joint. It is not uncommon to find on x-ray that the Condyle Head is improperly positioned in the Joint space such that it is in intimate contact with the Tympanic bone. The consequence often is ear pain in the absence of infection, a sense of fullness, or stuffiness, in one or both ears, and sometimes ringing in the ears. If you go to the "X-Ray Views" page, you can see these reasons graphically.

I have some TMJ symptoms, but I just don't want to take the time, or spend the money for treatment right now. What will happen if I put it off?

It depends on how serious your symptoms are. The odds are that without treatment your condition will progress, because your TM Joints are in almost constant use, when you talk, when you chew, and even when you think they're not being used.

For more information please visit: www.leadingdentists.com or www.myotronics.com

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