"TMJ" Therapy: A Confusing Muddle

John E. Dodes, D.D.S.

"TMJ therapy is a “no-man’s-land” in which some practitioners act responsibly whereas others make extravagant claims and prescribe expensive treatment that is ineffective. A confusing muddle of diseases and conditions has been lumped under the term "TMJ disorders." The most common symptom of “TMJ” is chronic facial pain (pain lasting more than 3 months), often accompanied by difficulty in fully opening the mouth.

“TMJ” is actually the abbreviation for “temporomandibular joint,” the hinge joint that connects the lower jaw to the skull. Since the joint itself may not be the source of the symptoms, the term “temporomandibular disorders” (TMD) is more accurate.

TMJ disorders have been described as dentistry’s “hottest” area of unorthodoxy and out-and-out quackery [1]. Pains in the face, head, neck, and even remote parts of the body have been erroneously diagnosed as TMJ problems. Some practitioners also claim that a “bad bite” causes ailments ranging from menstrual cramps, impotence, and scoliosis to a host of systemic diseases.

The correction of a “bad bite” can involve irreversible treatments such as grinding down the teeth or building them up with dental restorations. The most widespread unscientific treatment involves placing a plastic appliance between the teeth. These devices, called mandibular orthopedic repositioning appliances (MORAs), typically cover only some of the teeth and are worn continuously for many months or even years. When worn too much, MORAs can cause the patient’s teeth to move so far out of proper position that orthodontics or facial reconstructive surgery is needed to correct the deformity. TMJ expert Charles S. Greene, D.D.S., of Northwestern University Dental School, cautions that plastic appliances should be used only when necessary, for limited periods of time, and never while eating.

MORAs are different from “night guards,” which cover all the teeth and are used to prevent abnormal wearing down of the enamel in people who grind their teeth while sleeping. Similar appliances (bite splints) may be prescribed to relieve muscle strain in patients with TMD. Night guards and bite splints do not cause teeth to become misaligned.

Plastic appliances are sometimes misprescribed when a patient’s joint makes a clicking or grinding noise, even when there are no other symptoms. Research shows that joint sounds without pain or restricted or irregular jaw movement do not indicate any disease process and that no treatment should be undertaken in these circumstances [2].

Some dentists use electronic instruments to diagnose and treat TMJ disorders. The diagnostic procedures include: surface electromyography (EMG), jaw tracking, silent period durations, thermography, sonography, and Doppler ultrasound. Use of these procedures for diagnosing TMJ is not supported by scientific evidence. Similarly, treatment with ultrasound or TENS (transcutaneous electrical nerve stimulation, in which a low voltage, low amperage current is applied to painful body areas) has not been proven effective [3,4]. Some dentists obtain TMJ x-ray films as part of their routine dental examination. These films should be obtained only when there is a history of trauma or progressive worsening of symptoms, but not as a routine screening procedure [5].

There are also physicians who refer patients with facial pain to unscientific “TMJ specialists.” Still worse is the collusion of self-styled “TMJ experts” with attorneys. Some dentists solicit personal injury attorneys by offering to certify accident victims as having accident-related TMJ injuries—including “mandibular whiplash,” a diagnosis not recognized by the scientific community. Attorneys have even been invited to free medico-legal seminars with a brochure stating that a patient “was awarded a settlement of over $100,000 for TMJ injuries alone . . . based on . . . emotional and physical distress resulting from the TMJ injury.” Ultimately, the insured public has to pay for such abuse with higher premiums.

There is considerable evidence that for patients with real TMJ problems, safe, simple, inexpensive treatments (such as warm moist compresses, cold compresses, ibuprofen, simple jaw exercises, and a soft diet) will produce similar high rates of improvement as do unsafe, complex, irreversible, expensive treatments.

Dr. Joseph Marbach, the late former director of both the Facial Pain Clinic at the Harvard Medicine and of pain research University’s School of Public Health, warned against surgery as a treatment for TMJ. Some procedures remove the disc between the skull and the lower jaw; others surgically reshape the entire joint or even replace the entire joint with an artificial one. Surgery should be considered for tumors, “frozen jaws," or other definitively diagnosable problems that can only be resolved through surgery. Patients should always ask how likely it is that the surgery will make the symptoms worse or cause other complications. Since surgery is not reversible, other alternatives should be exhausted first. If surgery is recommended, it is prudent to obtain a second opinion. A consultation with a member of the oral surgery department of a dental school would be ideal.

References

  1. Berry JH. Questionable care: What can be done about dental quackery? Journal of the American Dental Association 115:679-685, 1989.
  2. Greene C, Laskin D. Long-term status of TMJ clicking in patients with myofascial pain and dysfunction. Journal of the American Dental Association 117:461-465, 1988.
  3. Mohl ND and others. Devices for the diagnosis and treatment of temporomandibular disorders. Journal of Prosthetic Dentistry 63:198-201, 332-335, 472-476, 1990.
  4. Deyo RA and others. A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain. New England Journal of Medicine 322:1627-34, 1990.
  5. McNeill C and others. Temporomandibular disorders: diagnosis, management, education, and research. Journal of the American Dental Association 120:253- 263, 1990.

This page was posted on December 6, 2008.

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