|
 |
| |
Temporomandibular Joint Disorder management
is probably the most frustrating area in dentistry. I know TMJD patients can be treated with a high
degree of effectiveness, and a great deal of satisfaction. I have done it for 30 years. My long-standing hope has been that our profession would develop an effective and consistent treatment protocol for
TMJD patients. I am not aware that this has happened. Since I am retiring
this year, I have decided to offer one or two courses in my office to share what I have learned. Since
1985, I have treated 40-50 TMJD patients a year, mostly on a referral basis. Over ninety percent
of the people I treated have become and remained pain-free. Although TMJD has multiple symptoms,
pain is the one for which patients most often seek relief. The course dates are May 14-15 and
October 8-9. Our office can accommodate a maximum of 14 dentists per course. I will
do a program if four or more dentists register for a date. A decision on each course 2 weeks before, if
there are not 4 registrants. The course fee will be $750. Each dentist may bring one
assistant at no additional fee. I would encourage you to do so as they will receive separate training on
their role in patient management. The program is sponsored by Patterson Dental Supply and approved
for AGD, IDA, and IDAA continuing education credit. It will be very clinically oriented.
Clinical training is the key to successful patient management.
2 Day Course Schedule
ATYPICAL
TMD/FACIAL PAIN PATIENT PROFILES Paul Readhead DDS, FAGD
Compiled June 2002 Revised January 2010
These cases are not typical cases of temporomandibular joint disorder and comprise 5% of the patients
I generally see. However, they are indicators of the complexity of situations that can present to
you and how you can deal with them.
Howard #1 HL, a 55 yo male with full occlusion, except for 3rd molars. First
seen as a routine new patient in 1978. He had clicking in R joint, CL III skeletal/occlusal relationship. Patient was placed
in a Tanner Appliance, which reduced clicking. Equilibration was done six months later. Teeth #3, 4, 30, 31, and 19 were crowned
to improve structural integrity and stabilize the bite. Clicking remained greatly diminished. In April 1985, the patient noted
pain in the mandibular right quadrant, described as sharp, stabbing, and electric, of short duration, moderate to severe in
intensity, lasting for a few seconds to several minutes and then disappearing. It had the characteristics of a tooth with
a devitalizing nerve. It was episodic and unpredictable with no triggers, occurring from 2-3x/week to 1x/month. The patient
was not able to identify the exact location of the pain, but it felt like it was coming from tooth #30 or 31. On occasions
the pain would be so intense, it would "bring him to his knees," as he described it. On several occasions, he was
ready to have one or both teeth extracted. It was explained that this could well be TMJD pain of a non-typical
nature, which would not be eliminated by extraction. This pattern continued until March 2001, when
he complained of soreness in his right jaw joint. He indicated the previous pain seemed to be less of a problem in both frequency
and intensity. A different occlusal orthosis was made for him. All jaw pain is gone, and has not recurred as of this date.
Patient continues to be a patient in the practice.
Liz#2 LS, a 59yo
female with mostly intact occlusion, missing teeth #s1, 2,17,19,30,32. #16 is impacted, with no apparent pathology; #18 and
31 have both drifted mesially and completely closed the spaces where 19 and 30 were. #18 has slight mesial tipping. #31 has
significant mesial tipping. Patient was first seen as a routine new
patient in July 1989. In November 1989, patient presented with pain in the upper left side, which she attributed to #14. The
tooth was non-responsive to vitality test. Endodontic treatment was successfully accomplished, and the tooth crowned. The
pain persisted without change. Radiographs of the area did not reveal any pathology. In April 1990, an occlusal orthosis was
seated. By May 8, all pain and symptoms were gone. The patient has been on a night wear routine since that date with periodic
recurrences of pain. Orthosis adjustment and/or temporary increased wear time eliminates the symptoms. Patient
continues to be a patient in the practice.
Deb #3 DA, a 49yo female with mostly intact occlusion. #17 and 30 are missing, with 31, 32 tipped mesially
and the spaces 1/3 closed. Patient was first seen in late 1992, as a new patient. #14 was sensitive to biting and a crown
was done on that tooth. In February 1993, shortly after crown seating, the patient reported the tooth was no longer sensitive
to biting. On 5-98, during a routine recare visit; the patient reported pain on the UL side, which was vague and non-specific
as to cause. #16 had a fracture line in it. No other notable signs/symptoms were present. No identifiable cause was noted.
On 2-99, patient was seen for pain in maxillary left area. She had seen her physician because her throat and sinuses were
"sore." For 3 months. tooth #14 was very sensitive to biting, according to the patient. . This tooth was endodontically
treated, but the pain persisted. Patient was seen periodically, with the same symptoms, but no identifiable causes until March
2000, when she was referred for removal of tooth #16, which had a visible crack in it. The pain did not change after the extraction.
Anesthesia over tooth #15 eliminates the pain. The patient noted the pain was worse at night and less intense during the day,
and that she routinely takes 4-200mg. ibuprophen at bedtime so the pain does not awaken her during the night. A TMD history
was filled out, which was essentially negative. On 11-2000, patient returned with complaints of pain into the neck and shoulder.
She works long hours at a computer, both in her job and at a moonlighting job. She was referred to a local physical therapist
who co-treats TMD patients with me. This was somewhat helpful, but full resolution did not occur. Patient was not fully compliant
with the exercise routine prescribed. Patient presented 2-01, requesting that tooth #14 be removed. The request was declined.
Patient agreed to and was placed in a TMD appliance on 3-1-01. On 3-2-01, she called to say she had intentionally not taken
ibuprophen that night, to see what would happen, and had not awakened with pain in the morning. Except for one 12-hour episode
of pain, the patient has been pain-free since that time. This episode was precipitated when she went to work and left the
appliance at home. The pain episode occurred the following day. Patient was placed in night wear only, with no additional
episodes of pain.In 6-05, patient reported recurrence of pain.
She had discontinued wearing the appliance 5 months earlier and had experienced a gradual recurrence of pain.
She had reinserted the appliance full-time, but had not experienced any significant improvement.
Patient was placed in a deprogramming position again. Pain disappeared in 2 days and the appliance
was relined to full occlusal contact. Patient remains pain-free today. Recently
moved and may no longer be a patient here.
Joan#4 Joan, a 51yo female missing #1,16,17,29,30,32. She was referred by her
daughter, who was my patient at the time. She a chief complain of chronic, burning, pain in the right mandible,
radiating to the ear and pain in the left zygomatic area. Jaw movement aggravated the pain and limited
her talking. However, eating and having food in her mouth actually reduced the pain. No other signs/symptoms were present.
The patient was a registered nurse and brought an extensive written history of her problem, which she referenced often.Symptoms started in 1983, with occasional aching, progressing to severe pain with
swelling on the lower right. A root canal was done on tooth # 29 on 1-84, with exudate present (dentist’s statement).
The pain increased significantly and #29 was extracted. The pain continued to increase and at the patient’s insistence,
tooth #30 was extracted 3-84. A bridge was placed from 28-31 in 4-84. The pain continued to increase and
she said she had a metallic taste in her mouth. In 7-84, she sought help from another dentist who removed the original bridge,
saying it appeared to be made of non-precious metal and replaced it with a precious-metal bridge. The burning pain developed
at this time. It ran from tooth #27 to the ear. She
sought help from a number of dentists and physicians over the next three years. She had three appliances
made by different dentists. They decreased the pain somewhat, she stated. The maxillary anterior teeth
had been built up to provide some anterior guidance, as she had a pronounced Cl III skeletal relationship. That
had no noticeable effect. She had MRIs, CT scans, and a tomogram of the temporomandibular joints. The R
joint was abnormal on the tomogram, but the radiologist did not believe that was the cause of the burning pain.
She saw a total of 13 health care practitioners and went to several major institutions in the Midwest, prior to my
seeing her. She had been placed on many different medications. She was told
several times she was going to have to live with the problem.I saw
her in February 1988. Her TMD history was largely negative. She reluctantly agreed to be placed in an orthosis
on 3-29-1988. On 4-14-88, she indicated all pain was gone. A permanent cast splint was constructed
six months later after discussing treatment options. She remains comfortable to this day, as long as she
wears the cast appliance. Within 1 minute of removing the appliance, the pain is back. As soon as
she reinserts the splint, the pain disappears.
Julie#5 an
18 yo female, referred because of chronic headache and ear pain, with fully intact dentition, except for wisdom teeth.
Seen initially 6-96. PMH was unremarkable except for an accident the previous summer. She
had been swimming in S. Carolina, and had been hit by a large wave. She was spun several times and hit the bottom of the beach.
Several days later she had pain in her ears and went to a physician. Two different physicians in S. Carolina treated her for
swimmers ear at that time. She was seen several times after returning home, again being treated initially for swimmers ear.
She was also placed on several pain medications and a muscle relaxant, none of which changed symptoms noticeably.The TMD history was generally inconclusive. Transcranial x-rays were normal. It
was my sense that although she had some TMD symptoms, they were likely secondary to the trauma from the swimming accident.
She was referred to a massage therapist initially to see if muscle tension could be reduced or eliminated. The massage therapist
said the patient’s back muscles were so tight, she could not accomplish anything for her at that time. Patient was referred
to a physical therapist I work with on TMD patients. Patient was seen three times, and within two weeks the pain was gone.
I followed the patient for 2 months. No relapse occurred and no TMD management was done.
Susan:
54 yo female first seen 11-08 Symptoms of “pressure” headaches, facial and neck pain began
immediately after surgery that was performed in January 2007. Surgery was to remove an acoustic neuroma
from the 8th cranial nerve on the right side and was done in Los Angeles. The surgery caused
a loss hearing on the right side and significant loss of balance. She lost significant muscle function
on her right side because of severed nerves. When they grew back, they attached to different muscles, causing
facial synkinesis. She had problems with speech, an asymmetric smile, deviation on opening,
and difficulty knowing if her bite was “correct”. She stated that when she smiles,
her right eye tends to close and her smile line goes down rather than up The pain was aggravated by changes in barometric pressure, stress, riding in a car, and becoming overly tired.
She frequently had to go to bed until the pain decreased. It would typically start on the right
side and migrate to the top of her head and face, and also into the neck. She did have periods where
she was without pain for up to 2 weeks. Currently the pain was constant. Other symptoms: tinnitis in the right ear that had been present for many years;
popping noises in left ear. She rated herself as
somewhat depressed and as a 4 on a calm (0) to tense (10) scale. Her life event questionnaire was not unusual. She was currently working with a facial retraining specialist in Madison, WI.
to improve facial function and overcome the synkinesis and a local physical therapist. She
had seen a physical therapist in Illinois who did integrative manual therapy and suggested that some of her pain might be
from TMJD. She stated headaches are typically for
several weeks after the surgery and then subside. When her’s did not, she used a variety of medications,
which were not beneficial. She got relief in April 07 from craniosacral therapy, which was done by
her local PT. Relief lasted for several days. The intensity and frequency of her
pain had decreased over time, but was still a significant problem. This is a complex case. The symptoms are not from TMJD alone.
Surgery has altered innervation and muscle function. Physical Therapy was obviously helpful for Susan, both with short-term
benefits and over the long term as well. The letter I wrote to her dentist is below. Dear Dr. I saw Susan on 11/24/2008, for a comprehensive TMJD evaluation. Assessment
included a written history, which was reviewed, TMJD evaluation, transcranial radiographs, limited dental examination, review
of medical history, and an oral cancer/ head and neck examination. Head and neck evaluation and oral
cancer screenings were all within normal limits. Medical history was possibly contributory due to surgery
for an acoustic neuroma in January 2007. I have enclosed copies of radiographs for your records. Her chief complaint is of chronic headaches that began immediately
after her surgery in 2007 and have not resolved. The headaches vary significantly in intensity.
They typically are the least problematic early in the morning, becoming severe enough 3-4/7 days a week that she has
to rest for awhile before continuing her day. This is not always helpful in decreasing the intensity.
The patient cannot identify any pattern to the headaches. The radiographs do not show anything of significance. She has a collapsed joint
space on the right side, indicative of a displaced disc. The joint space on the left is larger than
typical. These are minor variations that are also seen in the asymptomatic population. This is a complex case. She has obvious
asymmetric functioning of the facial muscles. She has some underlying skeletal asymmetry.
She currently has some minor indicators of TMJD and stated that many years ago a dentist in North Carolina told her
she had TMJD. She remembers nothing else about that conversation and states she has not had symptoms that
have been problematic. So there are no significant indicators to show a connection between the headaches
and jaw function. It
is possible that the trauma from the surgery and intubation could have precipitated problems with the temporomandibular joints
and the headaches are the consequence. The changes in innervation on the right side of her face would certainly
create conflict in the functioning of the musculature of that area. This could easily be causing TMJD.
Unfortunately, there is no way to know the answer, except to treat her for TMJD and see what happens. Fortunately,
this involves reversible procedures if no improvement occurs. Given other causes of the headaches have
been looked at and generally eliminated, I am somewhat hopeful I can help her. We discussed this approach
in detail and she decided to proceed. She felt if we could reduce the headaches significantly, even if not eliminating them,
that this would be worthwhile. An occlusal orthotic was placed later that day. We
should get some feedback within 2 weeks and a definitive answer in 6-8 weeks at most. I also noted several other things. She most likely has “silent”
GERD that occurs during sleep. She denies any daytime symptoms. Her enamel has
a highly polished appearance. The anatomy of the posterior teeth is rounded and blunted, and she has cervical
erosion on the buccal surfaces of most posterior teeth. Several of these areas have been restored and the
tooth structure has been dissolved around them, leaving the restorations sticking out from the tooth. I
see this quite a bit. I asked her to try Prilosec OTC for 28 days and monitor closely for any symptoms
that would disappear. I suggested she then follow up with her physician and suggested she have an
endoscopy done toe establish a baseline condition for the esophagus. However, that should not be
done until we know about the TMJD. I also noted
her fingernails were cut extremely close and that she has calluses on the sides of her thumbs. I would
guess she chews on the side of her thumbs and perhaps bites her nails. I did not discuss this with
her at this time. We will see how the appliance therapy goes first. And this is
a bit out of my area. But I may suggest some counseling/therapy if that would appear like a good
idea. She certainly has some stresses in her life that could benefit from this approach.
This nervous habit could aggravate an underlying TMJD problem also. Thank you for the opportunity to assist with the care of your patient. I enjoyed the opportunity
to meet her. If you have any questions or comments, please feel free to call or email me at prdds@dentistryatsomerset.com I tell
patients what I expect will occur and that this does not always happen. It is the patient’s
decision whether to proceed or not, based on what I tell them. Susan wanted more improvement and was willing
to take a chance on treatment that might not work for her. She has obviously sought help from a variety
of sources. This case
had some setbacks during treatment. She improved and then relapsed. She fell on some
stairs once and was not always faithful about wearing the appliance when she felt good. I placed
her back in a deprogramming position and she got better. Placing her in a stabilization relationship
worked the second time. However, I have had cases where I have had to do that several times.
Often that is an indicator for the use of physical medicine, either P.T. or chiropractic.
Susan also had a tendency to discontinue wearing her appliance when she got better. I believe
that will result in relapses. I have released her from care as I think she has improved as much as I can
help with. I have enclosed a clinical note from her last appointment, when she was dismissed from
my care. Paul Readhead,
DDS
|
|
|
