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Temperomandubular
Joint Dysfunction (TMD)
TMD is a pain syndrome involving the muscles and ligaments of the temperomandibular
joint. TMD actually comprises a variety of different disease processes, ranging from true joint arthritis or inflammation,
to muscle pain (myositis), which is the more common problem.Short term distress can result from several causes. By far the
majority of cases are due to a sprain of the joint, similar to an ankle sprain...the muscles and ligaments get stressed and
need to heal.
Pain comes most commonly from muscle tension or spasm, due to a combination of physical factors,("loose"
joint ligaments),emotional factors (stress), some physical injury, or to some degree, a “bad bite”. Usually acute
onset TMJ is from injury to the delicate balance of the joint muscle functioning, either from opening too long or too wide,
chewing something for a long time, muscle tension, or a blow to the chin. However, most often there is no discernable
causative factor----the jaw just seemd to "go out", in the same way a back can "seize up".
The
Normal Joint
Your jaw joint is composed of a lower jaw bone, the mandible, which connects with your upper jaw,
or maxilla, in a joint space that includes a pad of cartilage between the jaws. This pad is similar to the discs in your
back or your knees, and acts to keep the two bones from rubbing on each other. This disc, or pad, is held in place by ligaments
and a muscle, a portion of the external pterygoid muscle. The disk (pad) moves along with the lower jaw as you open widely.
When you open just a little, it stays in place and the jaw simply rotates in place.
This joint is unusual, in that
the mandible must accomodate not only to the ligaments and muscles, but also to how your teeth meet together. An additional
complicating aspect is that this joint is bilateral, and the two sides have to work together. Trouble on one side can affect
both sides. Usually the joint which is "out" is the one which hurts, but ocassionally the situation is such that
the other joint is the one which hurts.
While this joint is delicate and has very complicated coordination with speech,
swallowing, singing, opening for your dentist, and chewing, the associated muscles have to be capable of very strong forces,
for chewing. Additionally, we all carry chronic muscle tension in our jaws; otherwise, we would walk around with our mouths
hanging open, looking rather bizarre. This chronic muscle tension, to offset gravity, is similar to the back tension we all
must assume to walk upright, and both are vulnerable targets for excess emotional tension. Most of us, at some point in our
lives, will usually have some problems with both of these muscle areas.
Ideally, our joints operate quietly
and smoothly but some of us will develop small pops or clicks as we chew or yawn. These are quite common, and should be discussed
with your dentist to see if any treatment is needed. Usually these noises are a result of the jaw joint slipping onto, or
off the articular disk. Often they will disappear with conservative menagement. If they do not go away, and are mild, often
they can be lived with. Becoming overzealous with treatment in this situation can be harmful, costly, and time consuming.
These management decisions you sould discuss with your dentist.
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Chronic TMD
For
information on acute-onset of TMJ symptoms, navigate to "SELF
CARE" page on this web site. For chronic symptoms, read on below.
Chronic TMD symptoms can range
from mild symptoms (such as having mild jaw problems in which you have to be careful what you chew), to more debilitating
symptoms which become distressingly central to a your daily awareness. In more severe TMD the jaw symptoms can dominate consciousness
for much of the day.
Learning to live with chronic TMD is akin to adjusting to any chronic disease, such as asthma,
diabetes, osteoarthritis, ulcers, and so forth. In some ways, the phases of adaptation can be akin to those of dying, with
denial, anger, bargaining, depression, and acceptance. While this may be an extreme metaphor, I use it to underscore that
TMJ dysfunction can be a major adaptation to undergo. In every case, a clear perception of the situation is important to achieve
the best adaptation possible. You have to become more familiar with your jaw and how it works (or doesn't) then everyone else.
Not attending to your condition and continuing to chew gum or drink lots of coffee, is to set yourself up for chronic problems.
In other words, denial doesn't work.
Essentially, chronic TMD patients have to come to terms with having a painful
joint limitation, which often is mild to moderate . This is usually purely a physical situation to start with, where the joint
ligaments or the muscle relations are "off" somehow. Later on, the stress of living with TMD requires more management
and in some cases this stress becomes the central issue.
The role of emotions, such as anger can play a major role
of TMD symptoms. Anger in TMD can be in two forms: anger at having the problem, which can be directed outward to others and/or
the dentist; or anger as a personality style, which can take the form of TMD symptomology.
Anger at a dentist
as the perceived causative agent of TMJ symptoms can become a fixation and may act as a distraction from attending to one’s
jaw problem. For example,holding onto a resentment towards an oral surgeon (who performed third molar extraction which resulted
in an eruption of a TMD complex) can be self-defeating. Often there is an underlying joint problem or dental occlusal (bite-related) structural situation before the extraction, which predisposes an individual to TMD problems,
and a routine dental procedure can “trigger” an underlying problem.
If there has been gross misconduct
on a professional’s part, then pursuing financial restitution might be a reasonable choice, but in my experience pursuing
legal steps is often futile and can prolong symptoms. Often it is part of the cycle of grief, that of blaming someone, expressing
anger.
As a psychotherapist, I have seen personalities who suffer from undifferentiated anger, poor self care,
and are vulnerable to developing TMJ problems, as well as back problems, poor posture,stomach ulcers, and other stress related
entities. It is my opinion that a majority (not all!) of chronic TMD sufferers have an underlying personality issue at play
which contributes to their TMJ symptoms. In referring to this, I will categorically state that not all TMD patients have an
emotional personality issue, and I am not “blaming the victim” here. Emotions can play into a causative role in
TMD, and I have seen some patients who are entirely over-fixated on their symptoms.
I also know that having TMD is often
very difficult and adapting to it can be a huge emotional struggle. Living with TMJ symptoms can be distressing and depressing
and warrent seeking help. Also, you should know that you can adapt to living with TMD, such that it simply becomes a part
of your life situation, and need not assume an overwhelming position in your daily experience. That is on the "acceptance"
end of the continuum.
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