Or: "I haven't got time for the pain"

Perhaps no pathological entity is as troublesome to both its sufferers and the dental profession as temporomandibular joint pain, or TMJ. Its validity as a legitimate diagnosis, as well as its precise definition and the appropriate therapeutic approach is the stuff of controversy, if not rancor.

Q: What is TMJ exactly? I went to my dentist complaining of a sore ear and throat, and she told me that my lower wisdom tooth was impacted and needed to be removed in a hospital. I waited merrily suffering for 3 months for a hospital appointment, only to be told by the specialist that, "I am not going to remove your tooth and that I think you have TMJ". What does this mean, as he thinks I am suffering from stress (don't know how he made the diagnosis, as I am sure he is not a psychologist as well. I assure you I am not suffering from stress, just a plain old sore tooth and ear.

A: TMJ is an acronym meaning "temporomandibular joint", the joint in which the lower jaw articulates with the base of the skull. In popular parlance, the abbreviation is applied to the putative condition known as temporomandibular joint dysfunction syndrome. It is a diagnosis of exclusion, often used when no other organic basis for a certain constellation of symptoms can be found. Although TMJ is often associated with ear pain, it also would include several other symptoms, such as limited range of opening of the jaw and joint noise. Although TMJ syndrome is often associated with stress, the actual causal relationship between the two is unclear.

You are right to be suspicious of the surgeon's dismissive attitude; it shows a casual attitude toward diagnosis, which is the cornerstone of good dental treatment. Indeed, pain can refer from the ear to the jaw, as well as the reverse; this may allow a possible non-dental cause for your symptoms. You may want to have your physician check out the condition of your ear, just to cover all your bases. If that proves fruitless, you may want to ask your dentist for referral to another oral surgeon for a second opinion. Your symptoms are not inconsistent with a pericoronitis, which can be caused by a partially impacted wisdom tooth.

Good luck!

Q: My orthodontist told me 9 years ago that I had beginning stages of TMJ--the jaw clicking and so forth. The headaches are getting worse, and I should probably do something about it, but from all I've heard there are few options. If you do the appliances there is no guarantee it will help and my insurance policy will only pay up to $2500.00 one time, period. I don't want to lose what help the insurance can give me on a procedure that may not fix it, but neither do I want to continue living with these headaches that won't go away for days at a time. What are the true options?

A: Temporomandibular Joint Pain Dysfunction, myofascial pain dysfunction, (TMJ, TMD, MPD) is a controversial diagnosis, and does not correlate well with organic and structural disease. Most people have some degree of joint noise, and this alone does not constitute a diagnosis of TMJ, nor is a headache necessarily caused by TMJ.

Your concern about the effectiveness of treatment is not inappropriate. You should not be in such a rush to start simply to maximize insurance benefits.

We would recommend you have a thorough diagnosis before you begin to chase treatments that may be inappropriate for your malady. There are usually some interdisciplinary head and neck pain practices and clinics associated with universities and hospitals. These practices have the advantage of approaching a diagnostic problem from the diverse perspective of multiple medical and dental specialties, and can give consideration to many potential causes of your headache, not just one (as would be the case of an orthodontist).

Q: I grind my teeth quite heavily in my sleep and at a fairly young age, I'm 43, I am already having difficulty with breakage and chipping. All of my front teeth have visible cracks. My dental insurance specifically disallows treatment for TMJ or any condition stemming from it. I have been told that bruxism is such a condition. Is there anything I can do myself as a palliative remedy for this problem? Would a sports type mouthpiece be of any help?

A: A sports mouth guard would prevent damage due to bruxism by preventing contact between upper and lower teeth, but it's unlikely you'd be happy sleeping with one. The relatively imprecise fit and bulk of these appliances make them uncomfortable for prolonged use. As a matter of fact, many dentist-made nightguards aren't so comfortable to wear, either, and many that are made don't get worn. Still, a professionally made night guard stands a better chance of being tolerated.

Other than that, reducing environmental stress is postulated to reduce bruxism, but this is not often possible...

As far as your dental insurance "disallowing treatment", that is not quite accurate. They are disallowing benefits for treatment. That doesn't mean you cannot have any such treatment done. There was a day (before the advent of dental insurance) when people willingly (if not happily) paid out of pocket for their health care. The fact that certain types of health care service are not reimbursable does not mean that such treatment isn't legitimate, appropriate, or even necessary. There is only one factor considered by insurance companies when deciding if a service is reimbursable - the bottom line. You should remember this the next time an insurance company "denies treatment".

Q: For several years, on and off, I have had the problem that at night, I grind my teeth in my sleep or just as I am about to fall asleep. I cannot even tell that I am doing it except that my girlfriend always wakes me to stop me. It began during a stressful period in my life which is long over. Unfortunately, even though I am on the whole happy and live a largely stress-free life, the tooth-grinding continues.

Does anyone have any advice? I want to stop doing it rather than wearing a dental apparatus as I have heard some people do.

A: There is no one way that is consistently effective in eliminating bruxism (tooth grinding habit). The best that can be offered is a night guard appliance that discourages the habit and limits damage to the teeth, joints, and periodontal tissues.

Usually, bruxism is idiopathic, that is, of unknown cause. Commonly, it is associated with physical or psychological stress. Occasionally, a subtle bite discrepancy can be diagnosed which will trigger a tooth grinding habit, but this is not often the case. Still, it's sometimes preferable to try a limited bite adjustment (occlusal equilibration) than to wear a night guard as a first attempt at treatment. We'd advise you to have your dentist check for occlusal interferences; failing that, try a night guard...

Q: What is TMJ?

A: TMJ is an abbreviation for temporomandibular joint; the term is sometimes used to refer to maladies apparently centered around the functioning of this joint. The TMJ is the joint which permits movement of the lower jaw (mandible) relative to the bones it articulates with at the sides of the skull (the temporal bones).

TMJ dysfunction (sometimes called MPD, or myofascial pain dysfunction) is a problematic, controversial diagnosis. It is generally a diagnosis made by a process of excluding other pain syndromes and pathologic states that have more objective signs and symptoms. It can manifest as pain, limitation of jaw movement, and joint noise. The causes are also poorly defined; the same factors that are frequently blamed are often found in subjects with no sign of disease. Demographically, it is predominantly found in adult females between the ages of 25 and 60 years.

Due to the fact that the causes of TMJ dysfunction syndrome are poorly understood, the modalities of treatment are controversial, and may include night guards, bite adjustments, muscle relaxants, and physical therapy. As is the case in many chronic pain conditions that don't yield well to treatment, victims of TMJ are frequent targets of practitioners offering therapy of dubious virtue. This is understandable, since "mainstream" therapy can't offer much more...

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