What to do for Jaw Pain (TMD, TMJ)?

 

Who do I see for Jaw Pain?

It has become common place for General Dentists to recommend night guards like aspirin for patients who experience any joint sounds, excessive wear on teeth and/or display any symptoms of joint pain.  In fact I see some dentists prescribing night guards on just about every patient to protect restorations from general wear and tear.  In addition, every week I see new articles published about “treating” TMD (Temporomandibular Dysfunction, “TMJ” or Jaw/Joint pain) with splints/night guards and it makes me question the legitimacy of these publications.  Unfortunately, too few dentists are taking time to do more than cover up the problem.

 

There are certainly those General Dentists that are quite qualified and very capable in treatment jaw pain (most local dentists will know who gravitates toward treating jaw disorders as most are content to send these difficult cases to that dentist who sees them regularly.  But it seems this trend is slowly changing as General Dentists are reaching more into specialized areas and working to increase their own patient pool.  The problem I have seen is that the only treatment ever prescribed seems to be a night guard.  And not a custom made and custom adjusted splint but a simple night guard made the same for everyone and rarely if ever adjusted after placement.  Kind of a one treatment for all joint pain approach.  Reminds me of a Far Side cartoon ….

 

 

 

So does the Night guard “work”?

 

Night guards and splints used to alleviate pain from TMD and Bruxism are generally made out of acrylic and cover the surface of the upper teeth to provide a controlled, smooth surface for the lower teeth to occlude against.  This surface is normally made so that when a patient bites straight down, all back teeth hit the splint at exactly the same time with the same force; front teeth may barely hit the splint or barely be shy of hitting.  Likewise, when the jaw is moved to the right, only the right canine hits and slides along the surface (the left side opens as the jaw shifts to the right and vice versa when the jaw moves to the left).  A well-made splint or night guard will provide an “ideal” occlusion in straight biting (what dentists call Centric Occlusion) and chewing right, left and forward (what we call cuspid or canine guidance).  There should be no interferences (dragging on the side opposite the movement or dragging in the back when posturing forward).  If there is no effort to produce this bite chair-side which typically takes several minutes of careful adjusting, then it is likely the night guard will dislodge during function or cause the jaw to shift one way or the other (effectively causing more damage and/or pain). 

 

A properly made and fit night guard or splint is very effective in reducing symptoms of TMD including reducing or eliminating pain, allowing the jaw to settle back to the center position and of course protecting the teeth from heavy wear from nighttime grinding (bruxism).  The problem with this type of treatment isn’t that it doesn’t help with symptoms, the problem is that it is a band aid and is generally not actually treating anything; it helps when being used because it provides relief for eight hours only to allow the damage the other 16 hours when not being worn.  Kind of like resting with a twisted ankle only to walk on it later and it flares up again.

 

“The problem with this type of treatment [night guards and splints] isn’t that it doesn’t help with symptoms, the problem is that it is a band aid and is generally not actually treating anything”

 

What are some basic rules to expect with typical night guards/splints?

Although there are certain specific “treatment” splints that I won’t mention because they are for very specific purposes beyond the scope of this article, a night guard or typical splint should always cover the entire upper arch as a partial coverage splint can easily lead to teeth over-erupting where there is no coverage which can (and does) create an openbite, a malocclusion where teeth will not touch when the splint is not in place.

 

 

A night guard or splint should not be worn more than 12 to15 hours maximum per day or there is a risk of the jaw settling to a more comfortable position which would make the teeth not fit.  The exception is if an Orthodontist is planning on correcting the bite with braces but does not know where the “true” jaw position is due to a lifelong shifting of the jaw; wearing the appliance full time (including during meals) allows the jaw to settle in its most symmetric and comfortable position which the Orthodontist (or even the Oral Surgeon) needs to identify before moving the teeth.

 

Remember that most adults bite into a “best fit” position of teeth which was created by the pattern and sequence of eruptions, the shape of teeth or even the fit of restorations later in life; a splint can tell your jaw where to bite instead of allowing the teeth to tell the jaw where to bite.  This difference is the shift we see and can lead to joint dislocation, jaw pain (musculature or actual joint/disc pain), frequent headaches and excessive wear of teeth. De-programming this shift is essential to correcting the occlusion and actually treating the TMD in many cases.

 

A night guard should be adjusted with a frequency dependent on how much  a patient’s jaw settles and how mush wear the patient experiences on the acrylic.  If a splint or night guard is placed but not adjusted, the doctor will not know when the jaw is moving; they will not know when wear facets or divots are creating causing the splint to lead the jaw to bite off center, and they will ultimately not know what is causing the actual jaw problems.      

 

When should a patient skip the General Dentist and go directly to an Orthodontist?

Probably the most important consideration with a patient experiencing jaw pain is who they should see first.  My recommendation is to see an Orthodontist if you have jaw pain or jaw noises first for several reasons:

 

1.     He/she will usually see you for no fee to assess your jaw

2.     The Orthodontist will take more extensive records specific to the joints

3.     The Orthodontist treats jaw problems and has to create functioning occlusions on every patient day in and out, year after year

4.     The Orthodontist is much more likely to identify the root cause of jaw pain when it is due to malocclusions; the Orthodontist can recognize subtle wear patterns suggesting shifts in the jaw

5.     The Orthodontist is going to treat you in the correct sequence; if there are crowns or restorative work, the Orthodontist will refer you to a General Dentist once the jaw position is identified/stabilized or corrected (or at least after you are informed of any underlying jaw shift)

6.     The Orthodontist will only perform his/her specialty; you have little to lose because any dentistry will still be sent to the General Dentist (many times including any splint therapy for those not wishing to treat with Orthodontics) with more information and any specialist recommendations that may help with restorative work, etc. including sequence of treatment and future considerations

 

If you do see a General Dentist first, ask question to make sure they commonly treat TMD or jaw disorders.  Ask what types of treatment they offer and if they refer to specialists regularly.  If you have wear on your teeth, make sure your dentist can explain why your teeth may be wearing (grinding alone may not be the issue; teeth can take function unless they are in poor positions).  If they are trying to treat your jaw pain by moving teeth with clear aligners, seek a second opinion with a Board Certified Specialist in Orthodontics before you spend any more time or money.  If they place a night guard or splint, make sure they adjust it to fit the bite (and check it during the adjusting to confirm correct occlusion with marking paper on the acrylic) and that they invite you back to re-evaluate the night guard every few months initially at least. 

 

 

With jaw disorders, you as the patient must take more of an active role in your treatment or you may find yourself with a dozen different splints and night guards, none of which help.

 

And finally, most jaw problems from poor occlusion are identifiable and treatable as children.  Don’t wait to be referred by the General Dentist who may not be able to identify the problem early or may not even see your child but once a year after the cleaning to say “hello”.  This is precisely why the American Association of Orthodontics and the American Dental Association recommend that EVERY child see an accredited Orthodontist by age 7 without the need for a referral.

 

If you have questions or comments concerning this or any orthodontic question, please feel free to make a complimentary new-patient appointment at either my Steiner Ranch location or my North-central Austin location on West 35^th street and MoPac.

 

Dr. James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio, 1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001 Valedictorian graduate from the prestigious Saint Louis University Orthodontic Program receiving the J.P. Marshall award for clinical excellence in 2001.  He holds a Bachelor’s Degree in Science, Doctorate in Dental Surgery, a post-doctorate certificate in Advanced Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics and a Master of Science Degree in Orthodontics and is a Diplomate of the American Board of Orthodontics.  Dr. Waters and his wife of 20 years live in Austin, TX with their 4 children where he has a thriving, multi-faceted Specialist practice with locations in Steiner Ranch and North-Central Austin.  You can learn more about Dr. Waters at BracesAustin.com.