The TMJ or temporomandibular joint is the joint that relates the mandible to the skull, and there is one for the right side and another for the left side. It is a complex and not very typical joint, due to its anterior displacement. The classical conception distinguished two articular surfaces, the mandibular head or condyle, and the mandibular fossa and the articular tubercle on the temporal bone of the skull.
These articulations are the ones that allow the mandibular movements of ascent and descent, protrusion, retrusion and lateralization in which the muscles of mastication participate, although none of them has a pure action, they can be classified as:
- Elevators (temporalis, masseter and internal pterygoid).
- Depressors (mylohyoid, geniohyoid and anterior digastric belly).
- Lateralizers/protusors of the jaw (external pterygoid).
What is bruxism and why does it occur?
The term comes from the Anglo-Saxon Bruxism which, in turn, comes from the Greek brychein, meaning “teeth grinding”. This is defined as an abnormal daytime or nighttime habit that includes clenching, grinding, tapping or chattering and/or rubbing/grinding of the teeth. This habit has repercussions on the teeth and the periodontal ligament that connects them to the bone, as well as on the muscles, bones and joints that link the skull and jaw.
It is an increasingly common disorder in developed countries, which usually affects men and women between 20 and 50 years of age, preferably, being less common in childhood and in old age.
Among the causes that may influence its appearance and development are the following:
- Stress. The presence of episodes of stress, anguish or frustration has been related to the appearance of bruxism, which has also been reproduced in animal experimentation models. Bruxism has been proposed by some authors as a liberating mechanism or escape route from all these stressful phenomena.
- Personality. Certain personality traits or patterns can favor bruxism, being patients typified within a type A personality or hyper-controllers (characterized by impatience, high competitiveness, loud and explosive voice, exaggerated body mobility, very responsible, with high frustration in the face of failure, fear of punishment, with a sense of time urgency) those who have been most related to bruxism, in an attempt to release non-externalized emotional tension.
- Alterations of the central nervous system, such as stroke, cerebral palsy, coma, or due to the consumption of stimulant substances (amphetamines, cocaine, ecstasy), or drugs such as antidepressants, antiparkinsonian drugs, which can trigger this type of habits.
- Occlusion. This is a factor classically related to the presentation of the habit and which today is questioned as the only factor, the thesis being accepted that its existence, together with stress factors, can provoke bruxism.
How can I identify if I suffer from a TMJ problem or bruxism?
First of all, it is worth explaining that the clinical manifestations of these problems are variable, limiting, on some occasions, the daily life of those who suffer from them. Among them are:
- Dental manifestations. Characterized by the appearance of wear on the edges of the teeth (bruxofacets), and/or in the areas close to the gum (abfractions), with increased tooth sensitivity, as well as a high rate of dental fractures.
- Periodontal manifestations. Characterized by the appearance of mobility in the teeth, and aggravation of gum problems in periodontal patients due to the so-called “occlusal trauma”.
- Alterations and pain in the masticatory muscles. It is very common to find sore spots in the masticatory muscles, difficulty or limitation of mouth opening, sensation of muscle fatigue upon awakening and during the day.
- Alterations in the TMJ or temporomandibular joint. There may appear noises when opening/closing the mouth, jumps in the jaw movements, preauricular pain, reduction of the degree of mouth opening, etc.
- Manifestations in the mucous membranes of the mouth. With the appearance of irregular lateral edges of the tongue due to pressure of the tongue against the teeth, or a white line on the internal mucosa of the cheek due to biting on the cheek.
Which professionals can help me diagnose and treat TMJ problems?
Undoubtedly the approach to this type of pathology requires a concept in which different specialists participate and collaborate, including dentists, physiotherapists and psychologists, to treat and/or prevent the effects of bruxism on the teeth, the masticatory and non-masticatory musculature and the TMJ, controlling factors such as stress and helping to manage relaxation techniques.
How to treat bruxism?
The first aspect to take into account in the treatment of a patient with bruxism is to help him/her achieve “jaw-aw awareness”. This means teaching the patient to palpate the masticatory muscles with his hands to check the state of contraction/relaxation of the muscles, or placing in his work environment some element that periodically reminds him of the need to carry out this maneuver can help a lot to achieve this objective.
The use of relaxation techniques, stress-relieving habits and avoiding the consumption of exciting substances such as coffee, tea, tobacco, alcohol or other stimulating and parafunction-inducing substances/pharmaceuticals is also effective. The involvement of psychologists, behavioral psychotherapists, neurologists or specialists in the treatment of sleep disorders may be necessary in some more severe and specific cases.
Of course, this treatment protocol includes the development of a splint or guard to slow down the wear and fracture of the teeth.
Many patients with this type of problem suffer from frequent headaches and pain in the neck, back and arm musculature, but do not correlate it with bruxism and jaw joint problems. Functional muscle disorders are the most common and account for 50% of the cases of temporomandibular muscle and joint disorders. The so-called myofascial pain affects the musculature of the head, neck and back with the presence of trigger points whose stimulation triggers regional pain located in the lateral portions of the head and neck, the area around the ears (front and back), the back of the head and neck, the area around the eyes and the temples. It is usually a more common pain in the morning that decreases throughout the day and is usually reactivated at the end of the day. In addition, fatigue and muscle weakness may appear in the affected area/s and even symptoms of tingling, numbness, and manifestations in the ear, such as ringing or pain, and even gastrointestinal discomfort such as nausea. The fact that the pain becomes chronic can cause anxiety and depression in the patient, aggravating the clinical picture.
Trigger points usually cause localized and radiating pain on stimulation and, over time, a limitation of the ability to open the mouth.
Therefore, bruxism and TMJ disorders can contribute to the appearance of “distant pain” that, in principle, we might think have nothing to do with a problem at the level of the mouth and its muscular functioning and, therefore, must be taken into account when it comes to diagnosis and treatment.
What are the latest advances in the treatment of TMJ disorders?
TMJ disorders usually require a multidisciplinary approach that includes dentistry, physiotherapy and sometimes psychological help to treat stress and pathological anxiety problems. In some cases also the help of the neurologist and even specialists in Sleep Medicine.
One of the goals of treatment is to alleviate pain and limitation of function associated with these disorders. The application of physical therapy through Physiotherapy has proven to be very effective and the incorporation of techniques such as radiofrequency or second generation high level tecartherapy have improved and multiplied the benefits of manual Physiotherapy treatments, relieving the painful symptomatology and promoting the healing of these injuries, with a minimally invasive, relaxing and painless technique for the patient. In addition, the possibility of using intraoral therapy with tecartherapy allows a more direct action on the nuclei of pain and a much more effective treatment with a significant reduction in recovery times.
In some cases, Botox injections are being applied in the masticatory muscles to reduce the contractility of the muscle and, therefore, the force that these patients can achieve during mastication and, above all, bruxist habits. It is a treatment that must be repeated from time to time to renew the effect.
Undoubtedly, these are complex and often chronic disorders that require treatment, follow-up and periodic maintenance to avoid recurrence or exacerbation.