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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 pain.

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 dental treatment.

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 pain anyway.

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.

EVALUATING CARE

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 has stopped.

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.

TREATMENT TIME

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.

TREATMENT TECHNIQUES

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

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 reduce inflammation.

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

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 (TENS)

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 unusually unpredictable.
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 OF MASTICATION

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

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.

DIGITAL STETHOSCOPE

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.

THERAPEUTIC EXERCISES

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 plan.

BIOFEEDBACK

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 pain.

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.

SOME RECOMMENDATIONS

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 specialists.

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 its end.
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.