111 N. Wabash Ave Suite 2011 • Chicago, IL 60602
Guidelines for Seeking Help
Gradually I realized that pain had taken
over my life— feeling it, thinking about it, and trying
to get rid of it.
—a 24-year-old teacher
Will I have to live like this forever?
—a 52-year-old carpenter
TMJ is not life-threatening, nor does it cause
progressive physical damage. That is to say, it hasn't been
conclusively shown that TMJ does progressive damage. As more
is learned about TMJ, and research is compiled, we may discover
long-term physical changes. But, as far as we now know, none
exist. Also, patients occasionally become suicidal because
of the pain they suffer, and some lives are all but destroyed
by pain. In that sense, TMJ can indeed threaten the life of
a person whose pain becomes unbearable, but TMJ itself does
not directly threaten the sufferer's life.
Because TMJ is a pain syndrome and not degenerative
or life-threatening, the necessity for treatment usually depends
on the patient's desires and degree of discomfort. Often in
the course of a dental examination, patients reveal symptoms
of TMJ. They may have occasional headaches or neck and shoulder
aches, but they consider these to be minor episodes and not
disruptive to their daily lives. Many patients have daily
headaches that are mild and relieved by over-the-counter pain
killers. These headaches are not interfering with the patient's
life, and he or she has accommodated them. Therefore, treatment
isn't indicated. Other people with a similar quantity and
quality of symptoms desire treatment for the problem. The
differentiating feature is the individual's response to the
REASONS FOR SEEKING CARE
Pain is usually the motivating factor in seeking
help. Treatment is also advisable if a patient is going to
begin sophisticated dental procedures such as reconstructive
work, bridges, or multiple crowns. This is advisable whether
or not the patient is exhibiting symptoms. Remember that the
symptoms of TMJ may be triggered or worsened by extensive
dental treatment when that individual has a predisposition
to the problem--a tooth-gearing problem and muscle spasms.
This is true even in a patient without symptoms. Many times,
the first TMJ symptoms a person experiences occur after extensive
Any person who is currently taking medication
for headaches or any other symptoms commonly seen in TMJ should
find out the diagnosis of the problem and the purpose of the
medication. If the diagnosis is merely descriptive or the
purpose of the medication is simply to mask the pain, then
evaluation for TMJ is desirable.
Remember: Pain is a result of processes occurring
in the body that are potentially harmful to a person's well-being.
Pain is not a disease in itself. If the reason for the pain
can be corrected, the pain will cease. This is what happens
in TMJ treatment. It follows that when the patient's pain
is gone, he or she need not rely on body-and mind-numbing
medications that at best can only mask the discomfort. In
addition, these medications aren't always effective with TMJ
Treatment whose only effect is the relief of
pain through medication ignores one simple fact: All pain
has a reason. But unfortunately, all the health care professions
combined haven't uncovered all the reasons yet. Nor is it
practical to assume that each individual practitioner can
possibly be, aware of all the known reasons for pain.
Medication for pain may be beneficial when
it's impossible to determine the reason for pain, or the pain
can't be dealt with in any other way. For example, after surgery
or a tooth extraction. However, a great many patients who
have sought TMJ treatment had been told repeatedly that there
was no reason for their pain. They often are taking large
quantities of pain-relief medication to mask their symptoms.
Frequently the reason for their pain is TMJ. It's usually
possible to treat the condition and eliminate the pain. Before
successful TMJ treatment was available, attempting to mask
the pain was the only choice. But fortunately, that is not
the case today.
With the practitioner you see, explore and
discuss the many different approaches used for TMJ treatment.
I can only take responsibility for, and speak knowledgeably
about, the treatment techniques I have developed and have
discussed in this book. I use these techniques daily in my
practice, and they have successfully resolved my patients'
problems in most cases. Because I cannot make specific judgements
about other techniques, you will have to weigh this book's
suggestions about what to be aware of when seeking TMJ treatment,
along with the advice of the practitioner you are consulting.
SURGERY OR OTHER DEFINITIVE TREATMENT
Many people who have had TMJ treatment still
have pain. In the course of treatment, many have had major
oral alterations, such as orthodontics, tooth movement, surgery
on the temporomandibular joint, jaw surgery, and equilibration.
The definitive (Phase II) treatment described in this book
is usually considered only after the patient is symptom-free.
No one can offer a "treatment guarantee," but if
Phase I treatment is unsuccessful, the definitive treatment
has little chance of succeeding.
Generally, definitive treatment should be considered
after three things happen:
1. The symptoms--pain and distress--are eliminated.
2. The signs--muscle spasms, for example--that the practitioner
sees are eliminated.
3. The movement of the lower jaw toward its normal position
Although the patient usually begins to feel
significantly improved in one to three weeks, the course of
Phase I treatment may last for several months. Even when there
is demonstrable damage to the jaw, if the patient exhibits
muscle spasms, we will treat the patient muscularly in Phase
I. If the patient doesn't respond to treatment in a reasonable
period of time, we will then make an exception in our protocol
and refer the patient for evaluation and possible surgery
of the joint itself.
PART-TIME USE OF THE SPLINT
When a splint is worn only part-time, the likelihood
of lasting success or success at all drastically diminishes.
This is only logical. The triggering mechanism for TMJ is
a problem twenty-four hours a day, and it is not under the
patient's conscious control. Any device designed to eliminate
the triggering mechanism will have maximum effectiveness only
if used full-time. When the device is out of the mouth, the
bite-triggering mechanism has full effect and may even be
enhanced. This occurs because the muscles have begun to relax
and have started to "forget" their protective role.
Most patients accept wearing the splint full-time
as a temporary and small hardship compared to the pain they've
been in. If the patient cant wear the splint twenty-four hours
a day, then treatment should generally not be considered at
that time. The chances of success are minute, and wastes the
patient's money and the practitioner's time.
FREQUENT AND ROUTINE OFFICE VISITS
In an effective treatment protocol, it is vital
to see patients regularly, usually weekly, during Phase I.
As mentioned, this treatment phase involves forcible relaxation
of the muscles and adjustment of the splint to accommodate
the new position of the jaw. When office visits are spaced
more widely than once a week, patients tend to progress more
slowly. They also have more pain, and the treatment is longer
and less predictable. Be specifically aware of the frequency
of these all-important visits.
HEAVY USE OF DRUG THERAPY
Pain-relief medication should not be necessary
during TMJ treatment. Usually within the first weeks of treatment,
patients experience substantial relief. In addition, multiple
therapies tend to confuse both the practitioner and the patient.
If symptoms and signs change, it's difficult to determine
which approach was responsible for the changes. An additional
and equally important reason for not using drug therapy is
that it's most often ineffective, and patients obtain rapid
relief without it. Thus, it's unnecessary.
It's unfortunate but true that many patients
recite a history of years of therapy without results. Treatment
time varies, and it depends on the patient's response to therapy.
This is impossible to predict, but patients typically respond
positively within a month--generally within the first three
weeks. On the average, Phase I treatment lasts six months
to one year.
TMJ treatment has a beginning and an end. It
is not a lifelong maintenance treatment. The first goal of
treatment is to eliminate the problem by artificial means.
When this is done, changes are made in the patient's mouth
so that the accomplishments of Phase I can be maintained without
treatment devices. You should not be a TMJ patient forever.
Many common techniques have been shown to be
of some value in treating TMJ patients and are used by some
practitioners. Some of these techniques are logical, since
TMJ is both a pain syndrome and related to stress. These techniques
are not bad in and of themselves, and some may help particular
patients more effectively deal with stress in their lives.
Some therapies help patients handle their pain.
However, they do not help the underlying reason
for TMJ symptoms, and therefore are seldom used to treat patients
in my office. But readers of this book may encounter practitioners
who do incorporate them in their philosophies of TMJ therapy.
Moist-heat therapy is sometimes used as a self-help
measure and is useful for home care. Some office treatment
uses this as well. It generally involves applying moist hot
towels or special devices to the head, face, and neck. The
goal of the treatment is to relieve pain by breaking the muscle-spasm
cycle. In this case, the heat becomes the irritant to the
muscle. It also stimulates circulation to the area and may
Before the development of the muscle-puncture
technique, which is fast and predictable, the moist-heat treatment
was certainly an efficacious therapy to use. However, the
needle-puncture technique breaks spasms and relaxes the muscles
so effectively that the heat treatment is no longer necessary.
Cryotherapy is an old technique that is sometimes
effective in preventing the spread of a headache. When used
in the office, a medication called ethyl chloride is sprayed
on the skin. This medication evaporates rapidly and chills
the surface on which it is sprayed. A more simple technique
involves putting a cold pack on the head, face, or neck when
the headache first begins. A cold pack works most effectively
on vascular headaches and has not been found specifically
effective in stopping the spread of muscular headaches. But
this technique helps occasionally, Again, the cold may serve
as the muscle irritant and break the spasm.
TRANSCUTANEOUS ELECTRO-NEURAL STIMULATION
With TENS, electrodes connected to a portable
battery pack are applied to the tender areas, possibly suppressing
pain in those places. The apparent action of TENS is to interfere
with the sensation of pain. It doesn't take away the cause
of pain, but acts to block the message of pain to the brain.
There. is some evidence to suggest that TENS stimulates the
release of endorphins, the body's natural narcotic. This mechanism
may provide some relief temporarily. In TMJ this relief is
Now that it is known how accessible the key muscles are in
TMJ treatment, and how easily we can relax them, TENS is neither
necessary nor beneficial to TMJ patients. However, in the
treatment of other pain syndromes, TENS may be very effective
and the most practical way to reduce symptoms.
ELECTRICALLY STIMULATING THE MUSCLES
Electrical stimulation of the muscles of mastication
is a Technique similar to TENS, but it doesn't suppress pain
directly. Its apparent action is to control the muscle spasms
in the muscles of mastication by stimulating facial nerves.
The concept of this treatment is that muscles may relax as
a Result of increased blood flow. This may indeed happen,
but it takes longer, uses a more expensive technology, and
is less predictable than the simple muscle puncture method.
Therefore, it isn't necessary in TMJ treatment.
HIGH-VOLTAGE ELECTRO-GALVANIC STIMULATION
The goal of high-voltage electro-galvanic stimulation
is to reduce muscle spasms and pain by applying a certain
type of electricity to various muscles. Its goal is similar
to that of the needle-puncture technique. The needle-puncture
technique is usually more comfortable for the patient, however,
and the results are faster and more predictable.
Ultrasound therapy enables heat to reach areas
that can' t be treated topically. It may reduce symptoms temporarily,
but it doesn't treat the cause of pain. Use of this kind of
device may increase the cost of therapy simply because the
technology is more expensive than the syringes used in the
needle-puncture technique. Ultrasound therapy is also less
predictable, and muscle relaxation takes longer to achieve.
The term Doppler-effect technology is used
to describe the development of technology that enables a practitioner
to hear through tissues in the body. It was originally developed
to monitor fetal heartbeat and later became used in assessing
the functioning of artificial heart valves. This same technology
is used in a type of stethoscope that enables practitioners
to classify sounds the temporomandibular joint makes upon
opening and closing. Currently, several researchers are trying
to correlate data from the digital stethoscope with various
types of joint derangements.
This instrument shows much promise for learning
what is happening inside the joint. It may give oral surgeons
a better picture of what they will find when they enter surgically.
At the present time, the digital stethoscope
has questionable value for use in TMJ treatment. Even when
a patient has joint derangement, the pain is most often caused
by muscle spasms, and treatment goals are usually achieved
without surgery. The digital stethoscope may be useful to
the oral surgeon when surgery on the joint is deemed necessary.
Some practitioners try to treat TMJ by retraining
certain muscles and/or the tongue. Sometimes the therapy includes
exercises that correct the position of the tongue and help
balance the facial muscles and the muscles of mastication
while in use. The exercises also attempt to relieve muscle
spasms. However, I have found that most exercises of this
type impede rather than aid the patient. On rare occasions,
certain exercises may be necessary during Phase II of treatment,
but they by no means should be part of a routine treatment
Biofeedback is a well-known technique for treatment
of pain and stress syndromes. Patients learn to control muscle
contraction by monitoring various body signals, thereby attempting
to relax sufficiently to stop the pain cycle. Electronic instruments
are used to indicate to the patient when the muscles are contracting.
This feedback mechanism helps patients make a conscious effort
to relax the muscles. Over time, patients can use the information
when they are not working with the machine, enabling them
to relax for longer periods of time. Some people find the
monitoring of relaxation very stressful in itself; others
have found the technique helpful in showing them ways to consciously
attain a relaxed state.
Biofeedback was once thought to be a panacea
for chronic pain syndromes. However, TMJ has a physiologic
trigger that is present twenty-four hours a day, and that
may produce symptoms at any time, whether a patient is relaxed
or not. Furthermore, if the cause of pain is eliminated, it
is not necessary to help patients learn how to cope with the
STRESS MANAGEMENT AND PSYCHOTHERAPY
A case can be made that every person, with
or without TMJ problems, can benefit from training in stress
management. Many TMJ patients have difficulty relaxing and
will describe themselves as "tense" individuals.
We know stress is a component in TMJ as well as in many other
disorders. The stress of having chronic TMJ symptoms will
often leave a patient vulnerable to other health problems
because of lowered resistance. Stress can also exacerbate
existing conditions such as high blood pressure. It makes
sense for all of us to learn how to deal with the inevitable
stresses in our lives and learn how to relax.
Many people, including some TMJ patients, have
difficulties in their lives that cause them to seek psychotherapy.
Some TMJ patients have sought therapy after completing treatment
because they wanted help in putting their devastated lives
back in order. Chronic pain sufferers often lead empty lives
when pain destroys, or all but destroys, any chance for normalcy.
Patients' family lives, careers, relationships, and leisure
activities become ruled by pain. Some patients are able to
rise above the pain and manage to carry on a facade of normal
life. Others become vegetables because of medications, and
they often lose their ability to be involved with other people
and in social activities. And, of course, many patients work
out in psychotherapy problems that have nothing whatsoever
to do with TMJ.
While psychotherapy can benefit individuals
for many reasons, I don't often recommend it as part of TMJ
treatment. My treatment for TMJ corrects a physiologic trigger
for pain and relaxes the muscles. It doesn't teach patients
to cope with the pain, rise above pain, or numb pain with
drugs. It eliminates the cause of the pain itself.
Because of my treatment approach, I cant advocate
or advise patients to seek the other therapies I've listed
here except in rare instances. In fact, in the first months
of therapy patients are advised to stop all other measures
they have been taking to help them with TMJ--chiropractic,
physical therapy, massage, whatever. Of course, if a patient
is already in psychotherapy, they aren't asked to stop seeing
the therapist. If they have been practicing transcendental
meditation for years, they can continue. But they are asked
not to begin any new therapies.
When this treatment approach is the only recent
change in the patient's life and the patient is improving,
it is logical to assume that he or she is getting better because
of that change. Using these other therapies, especially at
the beginning of treatment, would make it impossible to know
which therapies are causing which effects. The treatment approach
outlined in this book is predictable. If a patient isn't starting
to improve within a month, treatment is usually discontinued.
At that point, we re-evaluate the likelihood of success if
we continue or change the treatment regimen. We usually conclude
the chances are slim, and the patient is referred to other
Anyone who is seeking help for TMJ, or even
seeking evaluation and diagnosis, should look for a practitioner
who can treat the cause of the problem. Because TMJ should
not require lifelong maintenance therapy, and because therapy
should have a beginning, a middle, and--most important an
end, find out the reasons for the therapy you choose, and
If you suffer from regular TMJ symptoms, I urge you to find
a competent practitioner whose experience shows that TMJ can
be corrected with well-thought-out and methodical treatment.