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Treatment

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

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.

SPLINTS

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 the splint.

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 front teeth.

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 problem.

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 will have.

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 splint.

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 by others.

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 condition.

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.

MUSCLE RELAXATION

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 relaxation.

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 to.

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 per muscle.
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 symptoms.

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 muscles.

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 progress.

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.

PHASE II

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.

EQUILIBRATION

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.

Treatment Variations

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.

APPEARANCE

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 be symptomatic.

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 possible.

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 cases.

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 pace.

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 treatment.

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 was advised.

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.

PROFOUND CHANGE

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 bridges.

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 of relief.
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.