Temporomandibular dysfunction: holistic dentistry

DeLany/Tilley and move it posteriorly until it contacts the medial pterygoid muscle (Fig. 17). Medial pterygoid is found medial to the teeth and just posterior to the last molars. Apply static pressure onto the belly of the medial pterygoid. Use gentle glides approximately one centimetre (half an inch) in length, if not too tender. The attachments of medial pterygoid would be included in a complete examination as well as the muscular floor of the mouth, styloid process attachments, tongue muscles and other palatal muscles. However, this delicate work is best learned in a supervised environment and not appropriately described in detail within this article. A complete postural evaluation will examine for forward head posture and pelvic position, which may contribute to head placement. Since Louise has complained of lower back discomfort, the lower back and pelvis should be addressed at some point. An exercise programme to strengthen weak postural muscles will help to inhibit hypertonic ones as well as provide structural support for proper head placement. She should evaluate her sitting posture at the computer and pay attention to unnecessary leaning, particularly of the head, as well as clenching of the teeth when working. Several muscles are known to

A

B

Fig. 17 Medial pterygoid: pressing and gliding on belly of muscle.

contain trigger points (Fig. 18), which refer into Louise's familiar pain pattern and should be thoroughly examined and treated by neuromuscular techniques (Chaitow 1996), spray and stretch or injection (Travell & Simons 1983). These muscles include the temporalis, masseter, both pterygoids, upper trapezius, sternocleidomastoid, and suboccipital muscles and attachments, which may contribute to forward head position as well as to referred pain (Travell & Simons 1983, Kaplan 1988, Moles 1989, Bonica 1990, Cailliet 1992).

REFERENCES Bonica J 1990 The Management of Pain, 2nd edn, Vol 1. Lea & Febiger, Philadelphia, PA Cailliet R 1992 Head and Face Pain Syndromes. F. A. Davis Company, Philadelphia, PA

C

D

Fig. 18 Some of the trigger points that may contribute to Louise's pain: (A) sternomestoid; (B) upper trapezius; (C) temporalis; (D) masseter.

Cbaitow L 1996 Modern Neuromuscular Techniques. ChurchiI1 Livingstone, Edinburgh Kaplan A, Williams G Jr 1988 The TMJ Book. Pharos Books, New York, NY Moles R 1989 Ending Head and Neck Pain: The TMJ Connection. CGM Publications, Racine, WI Price L 1994 All you ever wanted to know about latex. Massage Message Magazine (Spring) Travell J G, Simons D 1983 Myofascial Pain and Dysfunction: A Trigger Point Manual. Williams & Wilkins, Baltimore, MD

Temporomandibular dysfunction: holistic dentistry L. Tilley Larry L. Tilley DMD 508 S. Wall Street, Calhoun, GA 30701, USA Correspondence to: L. Tilley Tel: +1 706 629 0131; Fax: +1 706 629 0299 Received March 1997 Accepted May ]997 i

Journal of Bodywork and Movement Therapies (1997) 1(4), 203-207 © Pearson Prefessionat 1997

Temporomandibular dysfunction (TMD) has been the source of a great deal of controversy in dentistry and medicine since Dr Costen described the condition and coined the term Costen' s syndrome (Thoma 1936). This controversy has centred around the aetiology and progression of the disease. Is it teeth (Ramfjurd & Ash 1985), joints (Farrer & McCurty

1983), musculature (Gelb 1985) or is it merely a psychosocial (Albino 1996) problem that can best be treated through psychotherapy and medication? Is it progressive, selflimiting or chronic (Albino 1996)? Many clinicians feel that the answer is all of the above; it is rarely a simple syndrome requiring a simple treatment. The effect on the individual

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varies greatly, as do the duration and progression of the disease. TMD is a complex set of signs and symptoms requiring a comprehensive diagnosis and often a multidisciplinary approach to treatment. Louise could face a very difficult and frustrating future trying to find someone to help her with her conditions. She could visit the offices of some health-care professionals who would lead her to believe that TMD does not even exist while others would say all we have to do is look at her bite. If she is lucky, however, she will seek help from a practitioner who understands the significance of the problem and its relevance to her signs and symptoms. Dr Major De Jarnette, the originator of the sacro-occipital chiropractic technique, writes in his publication Cranial Technique (1977), 'Every person we deal with is a potential TMJ patient ... The TMJ problem is a demanding area which if not corrected or balanced prevents our patient from a full restoration to health.' Unfortunately, just getting to a dentist may not be enough. De Jarnette goes on to say, 'The dentist is presumed to be knowledgeable about the teeth and gums, but often they are not knowledgeable when it comes to the mechanics of the TMJ as a health problem'. Even after finding a knowledgeable dentist we must remember that some patients are very 'straightforward' and respond to the most basic treatment. Others, however, require the most comprehensive, holistic and multidisciplinary approach. By the time many of these long-suffering patients have been diagnosed as having a TMD problem they have often become very serious pain and/or dysfunction cases. These patients require the practitioner to have the broadest possible knowledge or at least the understanding of many disciplines so that proper referrals can be made. Clinicians who treat TMD agree that it is affected by stress. Louise is certainly no exception. No one can

have an active social life, a family, a stressful career and be in pain for 2 years without developing an emotional component to her problem. Although academic researchers continue to report the psychosocial issue as being the primary aetiologic factor in TMD . (Dworkin 1996), most clinicians as well as clinical researchers feel differently (Cooper 1996). There are numerous psychological tests (Fricton & Kroening 1988) that can be utilized to determine a fairly accurate psychological profile for a patient, thus helping the practitioner understand its relationship to pain. A very simple chairside approach, however, would be to ask Louise if her pain and dysfunction affect her social, business or personal life. If the patient responds that she takes her analgesics yet continues to carry out all her daily activities, her emotional response to the problem is minimal: it is an inconvenience. If, on the other hand, she responds by saying that she cannot concentrate at work or get her work done, she hardly ever goes out or takes part in family activities, and she and her husband seldom have intimate relations then her problem has assuredly developed a significant psychological component. Despite the psychological aspect of the problem it is seldom 'all in the head'; none the less, hypnotherapy, biofeedback, deep muscle relaxation or autogenic training would probably be helpful in reducing her pain or its effect on her (Brown 1974). Louise' s overutilization of artificial sweetener could be a contributing factor to her headaches. It has been reported in a study by the US Food and Drug Administration (Gottlieb 1995) that aspartame can contribute to seizures, headaches, migraines, rashes, tinnitis, depression, insomnia, and loss of motor control. At the very least, Louise should consider a headache diary and an elimination diet to see if this or other foods or additives might be playing a role in her pain. Nutrition is a significant factor for

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any chronic pain patient. Louise's busy schedule would cause concern about her nutrition, as would her lack of adequate and consistent supplementation. A diet and nutritional analysis should be considered (Whitney & Rolfes 1993). As a chronic pain patient her sleep pattern should be considered. Many pain patients have a disturbed sleep pattern that prevents them from reaching the deeper levels of sleep; without reaching these levels the patients suffer a lack of muscle relaxation, which occurs in the fourth stage of sleep, as well as the feeling of rest and rejuvenation upon awakening. Many of these patients respond well to small doses of antidepressant drugs taken at bedtime (Foreman & Rolfs 1985). Although Louise's skiing accident by virtue of timing was most likely not the initiating problem for her symptoms, it is highly possible that it was a contributing factor in its perpetuation and progression. Her broken clavicle could certainly have led to a great many muscle problems, ranging from the sternocleidomastoid (SCM), which is most obvious, to the facial, cervical, shoulder, low back, pelvic and leg muscles. A thorough evaluation of the possible myofascial problems should be undertaken by a neuromuscular therapist, physical therapist, osteopath or chiropractor. Along with the possibility of the muscular component the problem could also be related to TMJ trauma (Foreman & Rolfs 1985), cervical spine injury (Bland 1987), or the development of a cranial osteopathic lesion (Magoan 1976). Chronic temporal and ear pain, which seem to be Louise's chief complaints, could be the result of a host of possibilities; the most obvious explanation would be myofascial pain. Ear pain could be attributed to the lateral and medial pterygoid, deep masseter and SCM (clavicular). Temporal pain could result from trigger points within the trapezius,

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Tilley SCM (sternal), temporalis, splenius cervicis, suboccipital and semispinalis capitis (Travell & Simons 1983). Other considerations for pain in the temporal region should include cervical problems, cranial osteopathic lesions, temporal tendinitis, temporal arteritis, Ernest syndrome, Eagle's syndrome, greater and lesser occipital neuralgia, and osteocavitational bone lesions (Ramer's cysts) (Shankland 1993, 1995). Lastly, we should consider the possibility of an interarticular temporomandibular joint problem, which could also refer pain to the temporal region (Okeson 1993). Several things are revealed concerning the TMJ itself when the patient's history is evaluated. Range of motion (ROM) is limited to 37 mm, while normal ROM on opening is 45-52 mm (Talley et al 1990). Limitations of 37 mm could indicate a significant masticatory muscle dysfunction or a chronic closed lock (disc displacement without reduction) (Stack 1990). Mandibular tracking 'presents sudden lateral shift to the left then back to midline when open'. What is expected with a right anteriorly displaced disk with reduction is deflection of the mandible to the right on opening, caused by the lack of translation of the right condyle down the posterior slope of the articular eminence. As the disc is repositioned over the superior surface of the condyle it 'pops on' with a click and the mandible shifts abruptly to the left. As opening continues both condyles translate normally and approximate midline positioning is restored, although full ROM is blocked by the musculature (Fig. 1). With an anteriorly displaced disc the condyle presses against the retrodiscal tissue in which the nerves and blood vessels of the joint are located. Pressure on this structure is often painful, and chewing gum and biting would exacerbate her retrodiscitis (inflammation of the retrodiscal tissue). Pressure on the exterior of the joint would also

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Fig. 1 Looking at patients with their teeth together a grid can be visualized and actual measurements made to help determine mandibular movement and possible dysfunction. The vertical line represents the midlines of the maxillary and mandibular teeth. The mandibular midline movement is drawn onto the grid. A sudden shift to the left would most likely appear like this drawing, with the mandibular midline first shifting to the right because of translation of the left condyle and only rotation of the right. This lack of translation on the right would be caused by a displaced articular disc (usually anteriorly or anteriomedially). The sudden shift back to the left would occur as the disc 'pops' on to the condyle. Normal translation would then continue and the mandibular midline would move back toward the centre.

indicate some inflammation of the joint capsule (capsulitis). Antiinflammatory medication would be helpful in reducing this inflammation, but without 'unloading' the joint, thus reducing the trauma, the medication would have little effect. As with any injured joint, the muscles that cross the joint become the protective splint of the injured joint, thus introducing a muscular component to the already painful condition (Okeson 1995). The aetiology of Louise's signs and symptoms could be explained by her previous orthodontics and extractions. Extraction orthodontics is not a problem in and of itself and can be very successful provided the mandible and therefore condylar position is taken into consideration when the teeth are aligned. Beautiful dental arches with optimal interdigitation of the teeth are not enough to maintain the mandible in an ideal three-dimensional position (Jankelson 1990). An anomalous

relationship of the mandible to the cranial base (ICD 524.1) is often the result. This can be considered a structural anomaly creating myofascial problems just as with other structural distortions such as a short leg, small hemipelvis, long second metatarsal, and short upper arms (Dr Janet Travell, personal communication). Some cases require maxillary alterations that will allow the mandible to function in a more ideal three-dimensional (neuromuscular) position before successful pain relief can be obtained. Although it is impossible to develop an adequate differential diagnosis without a more comprehensive history and a physical examination, this narrative seems to indicate Louise's TMD problem is a very significant aspect of her pain and dysfunction. She should be able to obtain some relief via many treatment protocols (even overthe-counter pain medication could help). However, she should expect the results to be short lived without correction of this very significant precipitating and perpetuating factor. It is impossible to say categorically that her TMJ problem is the primary aetiological factor, yet it is a significant feature of her problem that will need to be addressed before significant long-term pain relief can be achieved. Despite the mode of treatment chosen by Louise, it is important for her to understand the problem and take an active role through self-care. The following suggestions should be considered: • avoid gum and other sticky, chewy foods • avoid apples and thick sandwiches requiring excessive opening • improve nutrition through a better diet and supplementation • exercise: stretching (especially cervical and shoulders), strengthening, endurance • avoid long-term use of analgesics, which can result in rebound headaches

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• learn to use self-applied acupressure or neuromuscular techniques • learn relaxation techniques • avoid activities that aggravate the condition (lifting, sweeping, driving) • evaluate work station for possible postural irritants - keyboard too high, cradling phone with shoulder • keep headache diary • elimination diet to identify and cut out offending substances • avoid caffeine • evaluate sleep posture - on back with cervical pillow and pillow under knees or on side with pillow between legs • moist heat or cold compresses for temporal and cervical area • herbal therapy might be considered • continue to be active in family and church activities.

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apex o f the eminence with the disc in (approximately 4 5 - 5 2 ram).

m6vem~ni::~fth~e6ndyleim0ven; ::(:::::i:: iAers 6pen!;X;Sdpening ::::::;::::: :: t)fi:~f:app/SXlNaieiy 25 ram/:::: ::::::::;~Rep:r~dueedWith permission from T. J. i:;Segi~s:::and[~e: ,:;::( ::::£?):)SpaM The Clinical Management of Basic Orthopedic Appliances. lot ::sldpe:;f ~he ~tlcular :: Year Book, St Louis, MO.)

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REFERENCES Albino J 1996 Management of tempromandibular disorders (NIH Consensus Statement). Journal of the American Dental Association 127: 1595-1606 Bland J 1987 Disorders of the Cervical Spine. W B Saunders, Philadelphia, PA Brown B 1974 New Mind, New Body. Harper and Row, New York Cooper B 1996 The role of bioelectronic instruments documenting and managing TMD. Journal of the American Dental Association 127:1611-1614 De Jarnette M 1977 Cranial Technique SOT. Jarnette, Nebraska City, NB Dworkin S 1996 The case for incorporating biobehavioral treatment into TMD management. Journal of the American Dental Association 127:1607-1610 Farrer W, McCurty W 1983 A Clinical Outline of TMJ Diagnosis and Treatment. Normandie Study Group, Montgomery, AL Foreman D, Rolls D 1985 Whiplash and The Jaw Joint. Book Publishing Co., Seattle, WA Fricton J, Kroening R 1988 TMJ and Craniofacial Pain: Diagnosis and Management. Ishyiyaku EuroAmerica, St Louis, MO Gelb H 1985 Clinical Management of Head, Neck and TMJ Pain and Dysfunction. WB Saunders, Philadelphia, PA Gottlieb B 1995 New Choices in Natural Healing. Rodale Press, Emmaus, PN Jankelson R 1990 Neuromuscular Dental Diagnosis and Treatment. Ishiyuku

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EuroAmerica, St Louis, MO Magoan H 1976 Osteopathy in the Cranial Field. Journal Printing Co., Kirksville, MS Okeson J 1993 Management of TMD and Occlusion. Mosby Year Book, St Louis, MO Okeson J 1995 BelI's Orofacial Pain. Quintessence Books, Carol Stream, IL Ramfjurd S, Ash M 1971 Occlusion. WB Saunders, Philadelphia, PA Shankland W 1993 Osteocavitation lesions (Ratner bone cavities). Journal of Craniomandibular Practice 11 : 232-235 Shankland W 1995 Craniofacial pain syndromes that mimic TMJ disorders. Annals of the Academy of Medicine 24:83-112

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Stack B 1990 Diagnosis to Splint Construction. National Capital Center for Craniofacial Pain, Vienna, VA Talley R, Murphy G, Smith Set al 1990 Standards of the history, examination, diagnosis and treatment of TMD. Journal of Craniomandibular Practice 8:60-77 Thoma K i936 Oral Diagnosis. WB Saunders, Philadelphia, PA Travell J, Simons D 1983 Myofascial Pain and Dysfunction. Williams & Wilkins, Baltimore, MD Whitney E, Rolfes S i993 Understanding Nutrition. West Publishing Co., Minneapolis, MN

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anteriorly,

i;:i::::assemblytranslates to full opening and i:i; :begins to close normally (D, E) Until the : :disc becomes unstable and again pops' 0ff'::i i:~he head of the condyle. This condition iS: i ::::known as a displaced disc with reduction. :: ' :

CLOSED LOCK This Condition reflects a more serious dysfunction than does a displaced disc with reduction. The process is the same except the disc is unable to reposition over the condyle. In an acute case the patient usually has a limitation of opening of approximately 25 mm or less. A chronic condition usually results in stretching of the ligamentous attachment, allowing the patient to open wider but only with additional damage to the ligaments, disc and possibly the condyle.

(Reproduced with permission from T. J. Spahl The Clinical Management of Basic Maxillofacial Orthopedic Appliances, Mosby Year Book, St Louis, MO.)

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