The incidence of TMJ disorder is still quite high, but because of the “variety of symptoms, causes and treatments”, many patients do not know how to find a doctor, and a large number of patients complain in the network, but do not get the right guidance, and go to many hospitals, but do not get the most accurate diagnosis and treatment. As a doctor who treats this specific disease, I would like to help people understand this disease in the simplest language, know what treatment directions are available, and find the most suitable treatment for themselves.
TMJ disorders are classified in many ways, from symptoms such as pain, restricted mouth opening and joint noise, to changes in the shape of the face in some patients.
In terms of professional diagnosis, there are four main categories.
The first category is soft tissue problems, i.e. muscle problems (such patients have MRI that indicates good disc structure), with symptoms of pain with or without mouth opening restriction. This is a small percentage of patients, with the largest percentage occurring in the second category (articular disc category). Some of the muscle causes are due to trauma, some are due to inflammation in the oral cavity involving the muscle, etc. This type of patients sometimes heat compresses, their own training under the open mouth training, or targeted anti-inflammatory drugs slowly improve themselves.
However, I have seen a traumatic injury caused by an avulsion of the occlusal muscle, a dollar coin-like hematoma existed in the occlusal muscle, the entire mouth opening only 7mm, such a situation can not be relied on their own, our department used a lot of treatment methods, two weeks to help patients can open their mouths to eat normally, a month to restore the mouth opening 38mm. However, there are some patients who cannot recover the normal degree of mouth opening, and the longer it takes, the more difficult it is.
The second type is the joint disc disorder, which means that the MRI indicates that the joint disc is “reversibly displaced” or “irreversibly displaced”. For more information on the relationship between the two and what it means in practice, please refer to my other article “Repeatable and Non-Repeatable”. This type of patient is the most common. Simply put, patients with “reversible displacement” have a popping sound during the opening and closing of the joint (the popping sound can also be caused by many other reasons, so it is not necessarily a reversible displacement). many people let it accompany their lives.
But there are many people who suddenly have joint popping, or think that it affects their lives, then they can go to the hospital for help, but the reality is that the dentists agree that in the popping stage is not necessary to treat, I personally think that the treatment means of the various oral departments are relatively limited and indeed does not affect the patient’s function, so it is directly recommended that the patient adapt to the popping.
In fact, the popping is a change in the spatial position of the articular disc and the condyle of the mandible and the articular disc in the process of opening and closing the mouth: it is in a state of displacement from the articular disc when the mouth is closed, and the popping occurs immediately when it is reset in the process of opening the mouth. I think that when the patient has a need for treatment and we in the rehabilitation department have the technical means to deal with the problems of many patients with popping, then treatment is possible.
But the longer the popping, the more uncertain the outcome. I have personally dealt with patients who had bilateral popping for 10 years, and one side stopped popping, but the other side was stubborn and still popped. Because popping is a spatial position relationship related to the movement of opening and closing the mouth, we need the patient to fully understand the principles involved, and then educate the patient to correct many incorrect postures and habits, use jaw pads to cooperate, and skillfully control their joint movements, with the ideal end result of eliminating the popping.
We generally set the treatment period at two weeks, and if at two weeks the patient’s popping is still stubborn, or if the patient has difficulty with motor control, then we will discontinue treatment. Many patients are able to eliminate the ringing and many are not, but because they understand the cause of the ringing and have changed their bad habits and posture to the greatest extent possible, they are no longer upset by fear and, more importantly, they are able to avoid the progression of the joint disease to the “non-relocatable” stage that we will discuss below.
”Irreducible displacement” is the most common problem for patients, and it is indeed one of the most common categories, with the highest percentage of patients suffering from restricted mouth opening, distorted mouth opening, facial pain, and changes in facial shape. Many patients in this category have a history of joint popping, but the moment when the joint does not open the mouth, it also happens that the mouth is stuck open, cannot open to the maximum, and has painful opening. The term “irreducible displacement”, like “reducible displacement”, describes the relationship between the position of the articular disc in the process of opening and closing the mouth, that is, the articular disc is displaced to the front of the condyle of the mandible, which impedes the movement of the joint in the process of opening the mouth, commonly known as “stuck”.
Because there are ligaments behind the articular disc to restrict its excessive movement, the original normal up and down position relationship between the articular disc and the condylar process now becomes anterior-posterior relationship. The forward-moving articular disc restriction blocks the normal magnitude of forward sliding of the condylar process, and the opening of the mouth is restricted, and if you want to open it more, the condylar process wants to push the articular disc farther, which causes a great mechanical stress loaded on the ligaments behind the articular disc and causes pain. This is the main cause of restricted opening and pain.
But “irreducible displacement” does not necessarily mean restricted opening and pain! Many people have a displacement of the articular disc, and the body slowly adjusts to it, so that the posterior ligaments of the articular disc become longer and more relaxed, and therefore do not prevent the condylar process from sliding to the front when the mouth is opened. This is very common, and a high percentage of normal people actually have a displaced disc. Many patients who present with limited opening and pain on one side and have an MRI that reveals the other side is also displaced, but never feel any discomfort, confirm this.
After introducing the concept of “irreducible displacement”, let’s move on to the treatment of patients with “irreducible displacement”.
The following are the mainstays of treatment.
Surgery: For most patients, especially in the early stages, it is not recommended either by foreign guidelines or by myself, and should not be undertaken without any conservative treatment, as the trauma of surgery can be worse than the original problem, with a high recurrence rate (especially with arthroscopic surgery), and when recurrence occurs, surgery can only be repeated. Surgery is only indicated when there is severe wear and tear on the joint, when there is significant facial deformation, when conservative treatment does not resolve the pain and restricted mouth opening, and when the patient is clear about the risks and benefits.
Joint cavity injection: regardless of what is injected, an injection is an invasive treatment and is not considered conservative treatment. So small joint cavity, injected with a large amount of fluid, there is also some damage to the joint capsule, but for the joint disc adhesions, or joint inflammatory mediators obvious patients, the effect is often very fast and obvious, we also need to know the risks and benefits, and decide for themselves.
Hot compresses: this is the most mentioned by dentists, you can try, wet hot compresses with hot towels, no more than 10 minutes, if two days no effect, then there is no effect. Some people also use what moxa guilt, or other heat sources, anyway, pay attention not to burn, I have seen again outpatient seeking treatment for the patient’s ear before their own burns.
Acupuncture: Chinese medicine should have a different understanding of this disease than Western medicine, and can not make objective comments. Anyway, a treatment that does not have any effect for two weeks should be considered whether it is effective for you.
Rehabilitation treatment: rehabilitation treatment is not as simple as only physical therapy doing machines alone, but most of the rehabilitation departments in the region treat this disease by doing physical therapy with machines. In China, our department carries out comprehensive rehabilitation treatment for patients with all types of TMJ disorders, and designs individualized treatment plans for different patients and conditions.
For patients with “irreversible displacement”, there is still a very high chance of “manual repositioning” within the early two months, which means that there is a hope for a complete restoration of the normal joint disc position, which again proves that the earlier the treatment, the better the results. Because the displacement has taken too long, the soft tissues such as the joint capsule have already adhered to the contracture. However, not every patient who comes in early can be repositioned, and not every patient who is “repositioned” can eventually maintain a normal disc position.
In clinical practice, we do not pursue “repositioning” of the patient, it is best to “reposition” the patient (shorter treatment time, immediate relief of opening restriction and pain), for patients who cannot be repositioned by manipulation, the treatment of the rehabilitation department is to help the patient’s joint adapt to the new position, eliminate pain, restore opening and pain. For patients who cannot be repositioned by manipulation, the treatment of the rehabilitation department is to help the patient’s joint adapt to the new position, eliminate the pain, restore the degree of opening and function, and help the patient improve the symptoms. Therefore, we should not blindly pursue repositioning, but should be rational in our understanding of treatment modalities, and we should not simply think that “repositioning by manipulation is very simple and applicable to everyone” and “only joint disc repositioning is really good”.
The rehabilitation treatment is not only limited to the temporomandibular joint, but there are many factors that contribute to the pathogenesis of this disease, including incorrect posture and psychological state, which the rehabilitation department tries its best to help patients to correct and regulate. Patients in the rehabilitation department should have the lowest recurrence rate because they are treated from the source of the disease. Many patients also have cervical spine problems, which is even one of the factors for the onset of the disease, and the rehabilitation department also deals with them together, and you can see many patients exercising various neck and shoulder movements in the department.
The intervention of the Department of Rehabilitation of the Ninth Hospital in this disease has filled the gap of conservative treatment in China, and also brought the most mainstream and comprehensive conservative treatment methods and concepts from abroad to every patient, and the effect is evident to all. There are also a large number of doctors who have studied in the Rehabilitation Department of the Ninth Hospital who have brought this technology back to their own hospitals and provided the same treatment to patients in their own areas.
Oral exercises: In fact, there are many kinds of oral exercises that are designed for all different types of patients, and it is really recommended that you do not do them indiscriminately, as many of them have very different purposes, and only when you go to a professional hospital can you get the most suitable treatment plan for yourself.
Various prescriptions: the efficacy can not be evaluated, but we remember one thing, this disease many people are their own body will adapt, which is why male patients are far less than female patients, then in their own blind tossing for two weeks without any improvement, please do not continue such treatment.
Drugs: there are two main categories, one is the anti-inflammatory and analgesic class, no pain generally do not need to eat, some patients have bone wear and tear (that is, the third category to be said later) pain is obvious, or to eat for a period of time. Another category is nutritional cartilage, if there is no indication of bone wear, also do not need to eat.
Jaw pad treatment: jaw pad treatment is one of the most used methods in dentistry to deal with this disease, the efficacy is still certain, but because of the wide variety of jaw pads, inconsistent individual differences in doctors, the complexity and diversity of the patient’s condition, the effect also varies from person to person. However, I personally believe that the treatment of this disease only treats the joints without changing the behavior and posture, and it really doesn’t always go to the root.
Orthodontic treatment: generally not used as the main modality for this disease, and orthodontics also recommends patients with displaced articular discs to treat the arthrosis first.
Extraction: Usually wisdom teeth, must also be recommended by a professional dentist, and it is clear that the pain and restricted mouth opening are due to wisdom teeth before deciding to extract or not to extract.
Resting position: known as the god position by many patients, in fact, it is very simple and common position, everyone on earth, to submit to its gravitational force, then it should definitely be resting position. This is stressed by us that each patient must master and adapt. I think it is difficult to say the efficacy of patients who cannot learn the rest position.
To sum up the treatment for patients with “irreversible displacement”, it is not that difficult from the rehabilitation department, but “the longer the patient has had the disease, the lower the cooperation with the treatment, the lack of understanding, the obsession with the need to reset by manipulation, the lack of sufficient security for the future, the pursuit of perfection of the face, the charming melancholy temperament “It’s hard to say what the effect will really and truly be for patients.
The third category is bone wear, this type of patient can be combined in any of the above categories of patients, generally middle-aged and elderly patients, if unfortunately you are not middle-aged and elderly patients lack and have this problem, then my only advice, is to hurry to learn the rest position and maintain good cervical posture, the missing teeth to fill, avoid unilateral chewing, try not to eat hard things anymore.
However, many young patients, especially female patients, are very much entangled in this problem, and the fear of bone wear and face deformation makes them go around to doctors, and the internet is full of all kinds of speculations and fears that the face deformation will be more serious in the future, in fact, the face deformation will occur when the articular disc is displaced, at this time it is not the bone wear, but the vertical height of one side without the articular disc that makes the mandible In this case, it is not the wear and tear of the bone, but the lack of vertical height of the articular disc on one side that causes the mandible to be different from the left and right, or the left and right mandibles are not in the same plane and rotate from side to side, usually to the affected side, causing the face shape to change. The change of facial shape after the displacement of the articular disc is immediate and relatively stable.
However, if the resting position is not well learned, or if the joint is still chewing hard objects, the joint will be worn out by long-term pressure and weight bearing, and then the bone will be worn out and more serious deformation will occur. So again, the importance of the rest position should be emphasized. Some patients also complain that their muscles have atrophied. Inflammation of the joints can cause the muscles to be affected and atrophied, and the muscles will atrophy as the affected joints are used less after the disease, but as long as the joints are used slowly and correctly in the future, the muscles will slowly become stronger and fuller. Patients who are entangled in these problems I think need to be adjusted psychologically, to divert attention, and again how many people’s faces are completely symmetrical, and how many people will look at you directly from the front, the disease, can only actively treat and adapt to the physical changes brought about by the disease.
The fourth category is joint dislocation, many patients will confuse this with “irreducible anterior displacement of the joint disc”, which is completely two kinds of diseases, joint dislocation is too big to close up, not too big. The proportion of patients with joint dislocation is still relatively low, but the treatment of patients with dislocation does not have a very clear effect of treatment, here I hope they all recover as soon as possible. I would suggest that such patients should be checked for occlusal problems, and also need to change the habit of opening their mouths wide and learn good cervical posture.
This article has been in my head for a long time and I have been lazy about writing it, but when I saw too many patients so confused, I must have made up my mind to write this article. I was once a patient of this disease myself, the incidence is so high that it is difficult to not also na….
I often tell patients in the department that I had it myself, the first time it happened the day after the fatigue of chewing sugar cane, the morning the joint was stuck and the opening of the mouth was restricted. As for what methods were used, you don’t need to ask much, they are very professional methods and really can’t be handled by yourself.
The second time in 2014, at the beginning, the gums were only sore and swollen when eating cold food, I thought it was at most a tooth decay, so I didn’t worry too much about it, but suddenly one night the severe pain woke me up from sleep, mainly for several important chewing muscle pain, I started to pay attention to it, at first I judged it was my own recent fatigue, poor cervical posture caused by muscle problems, also immediately did the treatment, the symptoms were reduced, but the night pain also suggested inflammation. However, the pain at night also suggested inflammation.
I immediately sought a dental examination, and after ruling out caries, I finally focused on one of my wisdom teeth, all of which had grown in early. Finally I had this wisdom tooth extracted and the doctor who did it said that I should have had inflammation of the gums before. Therefore, the previous night pain was caused by inflammation, and the later chewing pain was caused by the wisdom tooth.
So many complicated problems happened to me on my own, and I still needed to seek help from two different departments of dentists to help me determine the problem. This article is written one week after the tooth extraction and the symptoms have completely cleared up.
TMJ disorders are indeed complicated, and patients with the same problem come at different times with completely different conditions, and psychological factors also affect the regression of this disease, which puts high demands on clinicians’ diagnosis, treatment and doctor-patient communication.