111 N. Wabash Ave Suite 2011 • Chicago, IL 60602
I haven't had any pain in days. I can't
believe it, but it works
—a 42-year-old stockbroker
Now that I'm not in pain, I'm not sure
how I coped before.
—a 28-year-old homemaker
Patients often think TMJ treatment is complicated
and lengthy. They envision wearing mouthpieces, doing endless
exercises, being hooked up to electrical devices, and attending
relaxation classes forever. Some believe that surgery is probably
inevitable. But when I describe TMJ treatment, as done in
my office, patients are surprised at how simple it sounds.
I divide my TMJ treatment into two phases,
with particular procedures unique to each phase. The goal
of Phase I is first to break the cycle of muscle spasm, thereby
relieving painful symptoms. We then go on to artificially
achieve the proper relationship between the upper and lower
jaw. In Phase I the lower jaw is allowed to move freely without
the influence of the tooth-gearing problem. In Phase II we
permanently or definitively correct the tooth-gearing problem.
The goal of Phase II is to finish active treatment, and in
most cases the patient is no longer a TMJ sufferer. Thus,
TMJ treatment has a beginning and an end.
Phase I treatment artificially removes the
underlying cause of muscle-spasm cycle, which is the trigger
for the symptoms and signs previously mentioned. Remember
that the symptoms are what the patients experience—pain,
muscle stiffness, ringing in the ears, pain in the temporomandibular
joint. The signs are those responses I observe or elicit from
the patient, such as pain upon touching certain muscles.
Phase I treatment involves two basic kinds
of procedures. Neither usually involves making any irreversible
changes in the patient's teeth. Because the treatment of Phase
I can be reversed, it can be used as a confirmation of diagnosis
as the patient's signs and symptoms disappear. If a patient
doesn't respond (this happens in a small percentage of cases),
he or she usually hasn't been permanently altered in any way.
In other words, a patient who doesn't respond is no worse
off than when treatment was begun.
A part of Phase I treatment involves placing
a device in the patient's mouth. The device is commonly called
a splint. Many patients I see, or readers of this book, might
say, "Oh, yes, a splint. I had one of those, and it didn't
help." Or some might say that it made their symptoms
worse. Others might say that the splint helped for a period
of time. Still others obtained full relief with the use of
Throughout the world, TMJ therapy uses numerous
different kinds of splints and appliances. Some are what we
call "placebo splints"; they have no therapeutic
action other than to give the patient a sense that treatment
is being administered. As with any placebo treatment, approximately
20 percent of the patients will experience some relief.
Other splints are designed to move or force
the jaw into a prescribed position that is determined, sometimes
arbitrarily, by the practitioner. Some practitioners believe
that athletic mouth guards, custom or standard, can be worn
at night and produce some results. However, the technique
I have developed over the years and currently use is designed
to free the jaw and allow natural repositioning to take place.
I developed my treatment splint after working
with and studying numerous other appliances and devices. Although
a small percentage of patients responded positively to the
other devices, I became increasingly dissatisfied with what
I considered to be an unacceptable proportion of patients
successfully treated. Twenty to 40 percent is just fine if
you are one of the successful two-fifths. However, that leaves
many patients with little or no relief for all their efforts.
The splint is made out of plastic and is fabricated
to fit inside the upper teeth. It looks like an orthodontic
retainer without the wire going across the outside of the
This splint is designed in such a way that
when the patients put their teeth together, the lower front
teeth touch the front part of the appliance and the back teeth
are held slightly apart. This prevents the back teeth from
gearing together and, in effect, keeps the teeth apart without
conscious effort. This instantly eliminates the tooth-gearing
The splint is necessary to remove the triggering
mechanisms that program the neuromuscular system to keep the
jaw in an abnormal position. Remember that without this abnormal
"program" the jaw knows where it wants to go. The
muscles, through the reflex mechanism, have programmed the
jaw to go into a position that, on the surface, tends to protect
the teeth, the jaw, and the temporomandibular joint. But in
reality this protective position may send the muscles into
spasm. The object of the splint is to allow the jaw to go
back to its normal relaxed position. It doesn't do this all
at once, but gradually in progressive stages.
With my treatment concept, only the front teeth
contact the splint. This is done for two reasons. During treatment
the jaw is repositioning itself. The splint itself creates
an interference in this process, and the farther away the
splint is from the joints the less effect the interference
The other reason for this splint design involves
the practicality of treatment time and the number of days
between visits. No splint can be perfectly adjusted, and throughout
Phase I treatment, the jaw is constantly moving in response
to the splint. The back teeth aren't involved in the splint
because the complexity of their gearing with the splint would
make it almost impossible to adjust properly. If treatment
progresses at all, it progresses more slowly.
So, we want the splint in an area of the mouth
that is easy to work on, thereby improving the chances of
getting the adjustment correct during each weekly visit.
TMJ is a problem twenty-four hours a day. The
tooth gearing problem that creates the spasms doesn't come
and go. The muscles are generally in spasm all the time, although
the patient's symptoms may come and go and vary in severity.
When the patient wears the splint, the muscles start relaxing.
When the splint is removed, the triggering mechanisms still
exist. The muscles will then begin going back into their "limping"
pattern. This, in effect, diminishes or eliminates the benefit
derived from the splint
For this reason, patients must be willing to
wear the splint twenty-four hours a day during Phase I treatment.
This is essential to the success of the treatment. The only
time the splint is out of the mouth is when patients are eating
or brushing their teeth. Some patients have said that in previous
TMJ treatment they wore their splints only at night or for
a certain number of hours each day. This is usually ineffective.
Wearing a splint erratically never allows the
muscles to fully relax. This treatment might work for a patient
who has mild, intermittent symptoms. In these cases the splint
provides temporary relief—much like taking an aspirin.
But this approach can't eliminate the tooth-gearing problem.
Patients often say they notice the difference in the way their
teeth fit together when the splint is out for the short, but
necessary, periods to eat and brush. This is because of the
muscular relaxation that has taken place.
Another question patients often ask is whether
each splint used is the same. While the splints are basically
all of the same design, they are made to treat each patient
individually. Plaster casts of the patient's upper and lower
teeth are made, and then these casts are used to fabricate
The device is seldom visible in the patient's
mouth. However, because it is a foreign object in the mouth,
it feels strange at first. The patient may speak with a noticeable
lisp for the first few days. This lisp usually goes away in
a short time, or it becomes so slight it's barely discernible
An occasional patient may need TMJ treatment
but for various reasons may be unable to have even a slight
speech problem for a short time. I've treated actors, radio
and TV personalities, and singers for whom a removable splint
was unacceptable. In those rare cases I use a non-removable
splint fabricated on the patient's teeth.
The non-removable splint has some important
disadvantages, so I use this approach only when the standard
splint is completely unacceptable. One big disadvantage is
that it costs significantly more. Because it is fabricated
on the teeth, certain dental procedures such as bonding or
crowning must be done. This involves more "chair time"
and office visits to get started. Any repairs on the splint
must be done in the patient's mouth, again requiring more
complex dental procedures.
The non-removable splint may require initial
definitive changes in the patient's mouth—crowns and
bridges, for example. In the rare event TMJ treatment fails,
the patient is left with both the pain and the changes made
in the mouth's original status. This may require still more
treatment in order to restore the patient's mouth to its original
These risks and options are made clear to patients
who require this kind of splint. Patients are told that treatment
goals can be achieved with either kind of splint, but the
non-removable type is slightly more risky and much more costly.
People who have TMJ symptoms are undergoing
a muscle spasm cycle—spasm, leading to contraction of
the muscle, leading to more spasm—because of the neuromuscular
system's protective mechanism. Therefore, it is necessary
and vital to actively achieve relaxation of these muscles
and break the spasm.
Relaxing muscles is not the primary objective of the splint.
The object of the splint is to allow the muscles, once they
have begun to relax, to function without tooth interference.
As the lower jaw moves toward its end relaxation point, the
splint itself will trigger muscle spasms. That's why frequent
office visits are necessary during Phase I treatment. We adjust
the splint and break the muscle spasms during these visits.
Actively relaxing the muscles of mastication
is just as important as wearing the splint. One part of treatment
can't do its job without the other. There are many ways to
relax these muscles. My technique is extremely simple in concept
and application. However, other, more complicated methods
such as drugs, electronic devices, and exercises have been
used. These methods are outlined in detail in Chapter 14.
Over the years, I have found that the key muscles
in the entire muscle-spasm chain are the Lateral pterygoids.
These are the only muscles responsible for directly opening
the jaw. Most of the time, actively relaxing these muscles
will cause other affected muscles in the chain to follow suit
and relax without direct intervention.
Unfortunately, the external pterygoid muscles
are not only small but hidden. Because of their location,
they are impossible to massage. When they are in spasm, they
also tend to be exquisitely tender to the touch. Their tenderness
is a key to diagnosing TMJ in the first place. Relaxation
of these muscles is rarely achieved by exercise.
It is well-known that when a muscle is in spasm
irritating it by some means tends to reduce the spasm. We
don't know why this occurs, although there are many theories
to explain it. As yet, these theories are conflicting and
we don't know the specific reason for this phenomenon.
You have probably observed this "irritation
factor" yourself. When you have a cramp, or a charley
horse, in your leg, you may automatically begin massaging
it. At first the massage makes the pain more intense, but
gradually the pain may subside and you may feel the muscle
relax. You are achieving the same relaxation of the muscle
spasm in your leg as is accomplished by breaking the spasm
in the external pterygoid muscles in TMJ patients.
In the Lateral pterygoids, the irritation factor
is created with a muscle-injection technique. It is the most
successful and comfortable technique I have found to relax
the muscles. A tiny syringe is used, but unlike other injections,
no medication is involved. The muscle is pricked with the
needle, thus creating the irritation needed to relieve its
spasm. There is little discomfort, because the injection is
given in an area of the mouth in which there are few nerve
fibers. And, as mentioned before, no fluid is injected into
the muscle. The muscle-pricking technique is used in each
office visit along with the adjustment of the splint.
In the vast majority of cases, the external pterygoids are
the only muscles treated with the needle puncture. In rare
instances, a muscle in the head or neck will be treated with
this technique if the muscle is particularly resistant to
There are many explanations for why this kind
of technique works so well and so quickly. Some attribute
it to the Chinese philosophy of acupuncture. Others base their
theories on Western medicine's neurological explanation of
why acupuncture works. However, no specific acupuncture points
are pricked. The muscle is pricked wherever it can be reached
because the external pterygoid muscle is so difficult to get
The relaxation results from "irritating"
the muscle, not from stimulating any specific location of
the muscle tissue. In short, we don't know why this treatment
works, but it is effective. In my experience it is more effective
than other forms of muscle-relaxation therapy. The entire
needle-puncture treatment usually takes less than one second
I have also found that using a very mild muscle relaxant will
speed relief and the course of treatment by helping break
the muscle spasm. Using a muscle relaxant by itself is not
effective in relaxing the key muscle groups. Conversely, not
using it doesn't affect treatment results overall. In cases
involving pregnancy or a sensitivity to the drug, we simply
skip this part of the protocol. This only means that it may
take the patient somewhat longer to recover.
The drug used is orphenadrine citrate. Patients
should feel no side effects. In fact, I say, "The only
time I want you to be aware of this drug is when you remember
to take it. If you feel any side effects at all—drowsiness,
change of mental alertness, or anything unusual, then we know
you are taking too much, and we'll cut your dosage."
Any drug is potentially dangerous, and we use this drug only
to work on muscle relaxation. The dosage is minimal.
RESULTS IN PHASE I
The treatment combination of the active relaxation
of the external pterygoids and the use of the splint sometimes
brings almost immediate and dramatic relief. Occasionally
a patient will ask me what kind of drug is injected into the
muscle to create this relaxed, loose feeling in the jaw. Even
though patients have been told no drugs are used, they still
are often amazed at the swift response.
Most of the time, however, treatment progresses
more slowly. Patients typically begin feeling significant
relief within the first month—generally in the first
couple of weeks. Does this mean the symptoms will disappear
one day and never return? The course of improvement is, unfortunately,
rarely that simple.
First, the severity and frequency of symptoms
decline. Patients may notice they aren't bothered by such
constant nagging pain. Some patients report that improvement
begins when they no longer wake up with a headache. Others
are more or less symptom-free for a few days, then for a day
the symptoms come back with all their previous severity. There
is no way to predict the course of relief. But, while treatment
has peaks and valleys, the general trend is usually toward
less severe symptoms or increasing amounts of time free of
It's interesting to note that the severity
and frequency of patient's symptoms at the beginning of treatment
have little to do with rapidity of improvement. A patient
with fairly mild symptoms may have a long, slow climb to relief.
A patient with severe symptoms might improve rapidly. There
is no way to predict this when beginning treatment.
For Phase I treatment to succeed, the patient
must commit to weekly visits. The reason for this involves
the constant and unpredictable shifting and changing of the
lower jaw's position. On the day of the visit, the splint
is adjusted after the needle-puncture treatment to relax the
Within hours after leaving the office, the
patient's teeth are no longer gearing properly with the splint,
but the muscles are seldom affected immediately. Toward the
end of the week, as the next office visit approaches, the
symptoms usually begin to return. As treatment progresses,
the symptom- free periods become longer, and often the patient
will be tempted to cancel the weekly appointment. However,
early in treatment, this relief doesn't last, and the muscle
spasms recur and may stop, or even reverse, the patient's
Phase I treatment usually takes four to twelve
months. There is no way to predict who will progress quickly
and who will take longer to recover. But this portion of the
treatment ends when three things happen in unison. First,
the symptoms disappear. Next, the signs disappear. And finally,
the movement of the jaw has stopped. These changes must occur
together for a period of one to two months, while the patient
is continuing routine weekly visits. Only then is the patient
evaluated for Phase II treatment.
The splint has created an artificial environment
in which the jaw can relax and assume a normal position. The
needle puncture has relaxed and eliminated the muscle spasms.
The result is a normally functioning jaw mechanism and relaxed
muscles. The splint has allowed this to happen.
However, the splint, which has allowed the
symptomatic recovery to take place, can have a detrimental
effect on the teeth and gums. It's imperative that Phase II
treatment involve the removal of the splint. But suppose we
simply took the splint out and ended treatment. In the overwhelming
majority of cases, the symptoms would return, usually in a
very short time, if not immediately.
The options available for Phase II treatment
depend on conditions in the patient's mouth at the time of
evaluation. The most common procedure for Phase II is an equilibration.
This procedure involves reshaping the teeth so they gear together
in the way determined by Phase I. This is done using a dental
drill to remove some surface area from the teeth and create
a harmonious relationship between the teeth as the jaw goes
through all its motions. With this harmony, further muscle
spasms are unlikely to be triggered.
Equilibration usually takes about three to
four hours and is generally done in one office visit, although
occasionally follow-up visits are necessary. While spending
three to four hours in a dental chair isn't fun, this procedure
is usually painless. The amount of surface area removed from
the teeth is minute, and the patient rarely needs to be anesthetized.
I am often asked whether TMJ can be caused
by only one tooth being out of alignment. Although it is possible
for a gearing problem to be exacerbated and symptoms triggered
by a change in one tooth, this is rare. Equilibration is rarely
as simple as reshaping one or two teeth. Equilibration is
also often done on replacement teeth—crowns and bridges—or
on fillings and inlays.
There are times when instead of taking away
tooth surface, we need to add to it. Nowadays dentistry has
techniques, such as bonding, with which to build up tooth
surfaces. However, bonding material is not as strong as enamel
and will eventually wear away. Therefore, when bonding is
used to build up a tooth, it is a temporary solution used
only to verify the success of Phase II. When bonding confirms
that the teeth are gearing properly, the bonded tooth is replaced
with a crown.
For some patients, an important part of Phase
II treatment is to replace missing teeth. The loss of a tooth
will not, in and of itself, necessarily cause TMJ. But when
a tooth is missing, other teeth around it change their location
in the mouth and often create an abnormal gearing scheme.
While treatment plans for Phase II vary enormously
from patient to patient, the basic goal of treatment is the
same: to make the upper and lower teeth mesh in a way that
is compatible with all the motions of the temporomandibular
joint. No muscle spasms are created, and there is no abnormal
stress on the jaw. We eat, handle stress, exercise, and are
usually blissfully unaware of our jaws and teeth.
A few patients wonder whether Phase II treatment
will change the appearance of their teeth. Generally these
are patients who will have equilibrations and perhaps some
crowns. Some hope the dental work will improve the appearance
of their teeth, while others are afraid the necessary work
might flaw the appearance of their mouths in some way.
The gearing of teeth is independent from the
way they appear. A person with a movie-star-perfect smile
may have a serious tooth-gearing problem. The distribution
of some other people's teeth is obviously abnormal. Occasionally
a patient will tell friends who have abnormally appearing
teeth that they must have TMJ. "You can tell just by
looking at him," one patient said. While many of these
people have the pre-existing condition for TMJ, they may not
Actually, few people have perfect gearing of
the teeth. But in most cases the body is able to accommodate
what it has to work with. It's when the body can't adjust
to the incorrect gearing that the individual is vulnerable
to muscle spasms and triggering of symptoms. And gearing problems
and corrections might involve a "flaw" of one-thousandth
of an inch! The eye can't see this kind of minute discrepancy.
If tooth movement or reconstructive dentistry is necessary
for Phase III, then significant changes to appearance are
SOME EXAMPLES OF TREATMENT
What are Phase I and Phase II treatment like
on a practical basis? The easiest way to understand the procedures
and the way treatment progresses is to describe some specific
A PATIENT WITH SEVERE SYMPTOMS
Remember Jim Murray? He'd been injured in an
accident, and his symptoms started shortly afterward. His
main complaint was headaches—excruciating daily headaches
that seriously affected his life.
Phase I treatment with Mr. Murray proceeded
at an average pace. That is, he began to notice a marked improvement
about three weeks into the treatment. I adjusted the splint
and gave him the needle-puncture treatment during each visit.
This combination often brought noticeable relaxation immediately.
During treatment, the external pterygoid muscles
would go back into spasm, and usually by the time of the next
office visit Mr. Murray was experiencing symptoms again. But
after about six weeks, he was no longer waking up with headaches.
Those he experienced, usually late in the afternoon, were
manageable, because they were about half the severity of his
pre-treatment headaches. About eight weeks into treatment,
Mr. Murray was progressing at a fairly predictable and even
However, one week he was unable to keep an
appointment. By the time he saw me the next week, he was discouraged
because of the return of the morning headaches. They weren't
severe, but neither could he ignore them completely. He was
also afraid the return of symptoms could mean that treatment
could fail. However, after the next visit, Mr. Murray's symptoms
improved, and his morning headaches went away with normal
It was about three and a half months before
Mr. Murray happily announced that he'd had no headaches for
a full week. This indicated that he was probably nearing the
end of Phase I. We could then make a decision to go on to
Phase II, confident that his jaw had stopped moving. In Mr.
Murray's case, Phase II involved only an equilibration. His
total treatment time was about six months.
PREVENTING ONSET OF SYMPTOMS
Another patient mentioned previously, Marianne
Williams, was not experiencing symptoms when she came to me
for extensive reconstructive work. Because she had a positive
screening for TMJ and had, some years earlier, experienced
bouts with severe shoulder and neck pain and stiffness, treatment
When a patient isn't symptomatic, Phase I is
often very short. We look for the signs—the muscle spasms—to
subside. In Ms. William's case, this took about three weeks.
Phase II reconstructive work was done to duplicate the pattern
of the jaw and the teeth created in Phase I.
Ms. Williams's case was not particularly dramatic.
She represents the kind of case in which we attempt to prevent
the onset of TMJ symptoms. People with positive screening
are advised to have treatment when extensive dental work needs
to be done. In a way, it is an insurance policy that the investment
in the reconstructive dentistry will not need to be destroyed
at a later date in the event TMJ is triggered.
Joy Rubin's case represents a much more dramatic
example of treatment that profoundly changes a person's life.
Ms. Rubin came to me for bridges in her lower jaw. Initially,
she didn't mention her inability to move her head from side
to side. However, I noticed this in the evaluation and questioned
her about it. She had lived this way for many years and had
given up believing her condition could be helped.
At the time of Ms. Rubin's treatment, my treatment
methods were still being developed. Had she undergone treatment
five years later, the methods would have been much more established
and predictable. Ms. Rubin knew a number of methods would
be attempted in the course of her treatment.
Ms. Rubin agreed to come in for an entire afternoon
of trying the needle-puncture technique on various muscle
groups. I worked with the muscles, methodically eliminating
the spasms one by one. The motion in her neck began to return.
After the external pterygoid muscles thoroughly relaxed, she
regained total ability to rotate her neck normally.
Ms. Rubin's treatment represented a breakthrough
in understanding that the key muscles involved in the muscle
spasm cycle were the external pterygoids. This work with Ms.
Rubin led to a predictable protocol for Phase I treatment.
Ms. Rubin also wore a splint and continued to come in for
weekly adjustments and needle puncture. In about four months,
we were able to move to Phase II, which involved fabricating
This patient illustrates how TMJ treatment
can significantly change someone's life. Although Ms. Rubin
wasn't in pain, the restrictions on her range of motion seriously
affected her life. Before treatment, she had been unable to
look behind her without moving her whole body—potentially
dangerous when driving and prohibitive of participation in
any sport. Once TMJ treatment was complete, all the normal
activities of life were open to her again. Once, when she
turned around to talk to her young son in the back seat of
her car, he said, "You've never looked at me when we
were in the car before."
RELIEF FROM EXCRUCIATING PAIN
Julia Miller had also lost her ability to live
a normal life. Her situation was worse than Ms. Rubin's in
that she was experiencing excruciating pain. Her progress
in Phase I was slow, with many peaks and valleys. She didn't
begin responding until about three weeks after beginning treatment.
Throughout treatment, Ms. Rubin's symptoms
would increase or decrease in intensity as her stress levels
went up and down. However, over a period of about six months,
the number of symptom-free days increased, and her pain became
less and less severe. When she had remained virtually symptom-free
for about two months, we did an equilibration, and she has
not experienced symptoms since.
Sarah Johnson also had debilitating headaches.
She had all but discontinued a social life, she was depressed,
and the drugs she was taking left her unable to care about
much of anything in life. Ms. Johnson's case illustrates that
the severity of symptoms often has little to do with the rapidity
Ms. Johnson was fitted with her splint, and the needle-puncture
technique proved dramatically effective. After the needle
injections on the first treatment visit, she felt her jaw
relax and her headache subside. She then asked what type of
drug was used in the injection. It was nearly impossible for
her to believe that her longstanding symptoms could be relieved
with a technique that appeared so simple and involved no drugs.
Within six weeks of beginning treatment, Ms.
Johnson was symptom-free. She also stopped taking pain relievers
and spoke to a physician I referred her to about possible
withdrawal difficulties. Regaining her ability to think and
feel like a normal person, and living without daily pain,
made her able to resume relationships with her family and
friends, and even go back to work.
Treatment for depression and psychological
problems seemed absurd to her once her TMJ was successfully
treated. The only negative feeling she expressed about her
ordeal was a completely natural anger at having had to go
through so much before her problem was recognized. Her Phase
II treatment involved an equilibration and restorative work—some
crowns and bridges.
VARIATIONS IN PROGRESS
Barry Stern spent several months in Phase I
treatment but needed only one equilibration visit in Phase
II. It was a great relief to him to stop worrying about stress
constantly. Once he accepted that his problem was physiologically
based, he became much more confident and relaxed. He continued
to run regularly throughout treatment, and learned to consciously
keep his teeth apart instead of clenching down on them.
Sometimes a patient's progress is slow because of the type
of work he or she must continue to do throughout treatment.
Michael Maloney, the patient whose only complaint was severe
neck pain, progressed slowly at first because his carpentry
job required him to stress his neck daily. However, once his
symptoms were resolved completely, after about three months
in Phase I, they never came back. Phase II took several months
because he needed to have some orthodontics.
TREATING TMJ AND ANOTHER CONDITION
Occasionally a patient needs TMJ treatment
at the same time he or she is being treated for another condition.
Steve Smith was such a patient. He had been injured and had
to undergo cervical (neck) traction. Unfortunately, he had
undiagnosed TMJ problems, and the device necessary for the
traction triggered symptoms. This necessary device transmits
its force to the skull through the teeth. Another part of
the traction device transmits the force directly to the back
of the head. With a TMJ problem, forcing the lower jaw into
the upper jaw may trigger muscle spasms. In Mr. Smith's case,
the muscle spasms triggered severe symptoms, and he was referred
to me for an evaluation when the pain made him unable to continue
this type of therapy.
His treatment used a special kind of appliance
that directly transmitted the force of traction from his lower
jaw through his teeth to his upper jaw without triggering
muscle spasms. He was then able to continue with the cervical
traction he needed and later undergo successful TMJ treatment.
For patients having more than one kind of headache'
the treatment plan requires sorting out the various types
of headaches they are experiencing. Anna Martin, a beauty
salon owner, came to me because of severe daily headaches,
which she called migraines. About once a week she had the
typical visual changes associated with classic migraine. Ms.
Martin seemed to be a combination patient, because she did
exhibit some migraine symptoms. However, there was a large
TMJ component as well.
Her TMJ was treated, and by the end of Phase
I the majority of her headaches were gone. She still experienced
a moderate migraine about once a month, far less often than
the migraines had been occurring. For some unknown reason,
a TMJ headache can often trigger other kinds of headaches.
Once the TMJ is treated, the other types of headaches become
less frequent or even disappear.
COMPLEX PHASE II TREATMENT
In some cases, fortunately rare, Phase II treatment
involves a complicated combination of therapies. Harold Barry
received such treatment. Actually, his treatment had started
long before he came to see me. He had suffered a broken jaw,
which had presumably healed normally. However, from that point
on, he had constant headaches and neck stiffness. He went
from physician to oral surgeon to chiropractor and back again
through the cycle. By the time I saw him, he'd had two surgeries
on his jaw, but he still had the headaches. He also had undergone
orthodontic treatment, but he was still symptomatic.
Mr. Barry was in pain when he came to see me,
and his external pterygoid muscles were in spasm. Despite
his other treatments, he also had an extreme tooth-gearing
problem. Once the splint was in his mouth and his muscles
relaxed with the needle puncture, his symptoms went away almost
immediately. Mr. Barry agreed to continue with Phase II. Unfortunately,
this involved still another surgery to reposition his jaw—a
rare, but sometimes unavoidable, therapy. He also needed more
orthodontic work to get his teeth closer to proper gearing.
When that phase of treatment was complete, some necessary
reconstructive work was done. His treatment was completed
with an equilibration. Mr. Barry has been symptom-free for
many years. Fortunately, this kind of complicated case is
the exception rather than the rule.
THE PROSPECTS FOR SUCCESS
Once TMJ is diagnosed and Phase I treatment
begins, the chances for success are great. This is in part
because other causes for the pain generally have been ruled
out, and the diagnostic evaluation has shown clear signs that
TMJ does exist in the patient. This makes treatment failure
particularly frustrating. A tiny percentage of patients fail
to respond to any muscle-relaxation techniques, and their
symptoms don't subside. We try for about a month to see if
there is any resolution of the problem, but after that, the
likelihood of success is very slim.
Other patients will respond to the Phase I
therapy in terms of the signs. The muscles will be relaxed,
and the jaw begins to move into a normal position, yet the
patient still experiences symptoms. We don't know why this
happens. It's disappointing, sometimes devastating, and can't
be predicted before treatment begins. In cases like these,
patients are referred to other specialists for further evaluation.
There is nothing more to do for TMJ problems.
Most patients are able to complete Phase I
treatment in six to twelve months. If they aren't symptomatic
when they begin treatment, Phase I can be much shorter. Phase
II is individualized, so time estimates vary much more. Some
patients need a one-visit equilibration, and for others, Phase
II treatment lasts more than a year. However, in all cases
the goal is to treat the underlying cause of symptoms and
try to ensure they will never return.
Most patients who have heard about TMJ or who
know other people who have had various treatments for the
problem have heard surgery discussed as a possible solution
to their problems. In the majority of cases, surgery is not
and probably never will be needed. But, because they are so
often discussed and sometimes feared, surgical options for
TMJ are examined in the next chapter.