Why do people usually not know they have TMJ? Are the symptoms similar to other headaches or migraines, etc? How does one differentiate?

When patients present to a physician with headaches, migraines, ear pain, etc., most physiacians and dentists want to make sure there is no obvious reason such as infection, neurologic problems, or other disease process. If nothing is found, a palliative approach is usually tried using medication. Mnay times it is a trial and error approach and can often lead to multiple medications, and occasionally, even addiction.

Many of the symptoms are similar to other disorders so they are often misdiagnosed or simpoly a symptom diagnoses is made. Unfortunately, many physicians and dentists don't understand the many etiologic factors, which lead to craniofacial pain and temporomandibular disorders. Trying an oral appliance, without a good understanding of all the initiating and perpetuating factors, is no different than the shotgun approach of multiple medcations.

Note the enclosed symptom survey form. As you will see many of the symptoms of CFP/TMD are seen in many conditions. To differentiate this problem from others, a thorough history and physical exam is necessary. A Radiographic evaluation is important; yet, it alone will usually not give us all the information. Mandibular jaw function, postural evaluation, and multiple muscle tendon and ligament palpations must be performed. Those myofacial problems cannot be seen on any type of testing such as radiographic CT or MRI or blood studies. This fact may result in a diagnosis that nothing is wrong with the implication that the patients' pain is an example of stress, hormones, or psychological problems. The average patient seen in this office has seen four different practitioners prior to seeing us; most without training or understanding to recognize the problem.

Describe what the pain or sensation feels like when it is associated with TMJ or jaw or mouth pain of the face.

The pain sensation a person feels can range from an inconvenience, such as limitation of opening and annoying intermittent pain to severe debilitating pain. Often, the signs we see are (limitation of opening, worn teeth, deep overbite) do not match the symptom picture. People with significant signs may not have significant symptoms and vice versa. This is another part of the confounding nature of this problemhindering a simple diagnosis. Other initiating and perpetuating factors must be considered.

What age group or range does it normally affect?

The majority of craniofacial pain/ TMJ sufferers are women. Some studies show that they may represent dreater than 2/3 of all patients seeking treatment, so it certainly needs to be considered a woman's health issue. The predominat age is 20-40,; however, it can be a long-term problem, which reaches an unbearable pain level causing a patient to finally seek help. As mentioined patients too often endure a frustrating and expensive doctor to doctor search to find answers and a relief of symptoms. Even though women and their childbearing years report the most significant symptoms, men, young childre, adolescents, and the elderly often present with symptoms.

How do doctors or dentists diagnose the patients?

 Diagnosis requires a multifacated approach. A thorough medical/dental history must be the first step. A complete physical exam of the "upper quarter" of the body must be done to include a functional evaluation of mandibular function, palpation of joints, muscles, ligaments and tendons, a postural evaluation and appropriate radiography. Before considering the complex interrelationships of the structures of the upper quarter (chest up), a thorough dental evaluation should be performed. many times, patients are reffered for CFP/TMD only to find our a dental problem is the primary etiologic problem. Issues such as dental absesses, cracked teeth and third molar problems have proven to be the cause of suspected CFP/TMD symptoms.

Where do you get tested for craniofacial illnesses? Does this involve x-rays, etc?

You can best be evaluated for CFP/TMD by a dentist who is well trained in the subject. Dental school education offers minimal training in the dignosis and treatment of CFP/TMD. Most recieve training and certification after school through orginazations, which are dedicated to the advancement of the field and some offer post graduate certification. The largest such orginization internationally is the American Academy of Craniofacial Pain, which offers a 1-year hands on course with thorough testing for a Fellowship. A national certification test is availible through the American Board of Craniofacial Pain. Other orginizations that offer training in the field are the International College of Craniomandibular Orthopedics, the American Equilibration Society, and the American Academy of Orofacial Pain.

Although radiographic evaluation is important in diagnosing and treatingthis problem, it certainly can't stand alone in diagnosing the condition. other testing used may include: tomographic radiology, MRI, Doppler ultrasound, electromyography, madibular jaw tracking, sonography, vibratography, as well as other forms of medical testing.

Treatment may include various oral appliances, manual massage techniques, myofacial therapy, trigger point injections, and physical medicine modalities (i.e. therapeutic ultrasound, electrical stimulation, TENS, iontophoresis, low level laser therapy, etc.). Self-care must be continues at home. Permanent changes to the dental occlusion are sometimes necessary, but not always. Usually long-term maintenance is necessary through the use of some form of night appliance.

How much does the insurance pay for these procedures? Is it coded as regular copay?

Costs can vary depending on the severity of the condition. Insurance companies will often pay for some treatments, but each policy is different. Although a law was adopted years ago in our state which prevents companies from excluding treatment for a specific joint or by a specific practioner, many of them circumvented the ruling by setting a lifetime limit. Remember that the policy you have is between you and the insurance company and the doctor is not a party to it other than to try to help you get paid. Also, please understand that the way insurance companies make money is through your premuims and NOT paying out claims. Many policies will pay for temporomandibular joint surgery, yet not pay for more conservative and successful therapy. Our attempts to change this misguided philosophy of some companies have been difficult due to the status quo.

What are common ailments and how frequently do they occur?

The common ailments may vary significantly. The most common symptoms we see in our office includes: clicking joint, pain in the joint, limitation of mandibular movement, headache, ear pain without infection, and neck and shoulder pain. As you can see, many others can also be related. Most of these symptoms come and go, yet many are persistent and long lasting.

How do many of your patients arrive in your office? (by referral, word of mouth, etc.)

most of my patients are referred from physicians and dental specialists. Referrals also come from physical therapists, dentists I have taught, members of TMD organizations, successfully treated patients, and general dental patients.

How serious is the problem if you don't get it treated?

As I mentioned earlier, serious signs of a problem don't always produce serious symptoms, yet minor signs may produce significant symptoms. To understand this concept, we must realize that each of us has a specific physiologic adaptive range. It can be broader at times and reduced significantly at others. Good things like a marriage, can be as stressful to some as serious problems. overall, health, jobs, nutrition, realationships, fiances, and many other things can affect this range. As a result, we can't predict how serious a problem may become. We do know, however, that a dysfunction will continue to be a dysfunction and likely deteriorate more, yet symptoms are another matter. For some, the condition may remain an annoyance, for others a lifetime disability. 

What are some misconceptions about dental surgery/ procedures?

The greatest misconception by many dentists and patients is that an occlusal appliance will always solve the problem. Many of these are "no concept" splints. there are many types of oral appliances but, without a good differential diagnoses and choosing the correct one for the particular problem, they can not work and even worsen the problem. unfortunately, for many practitioners, you can't see what you don't know or, as the old addage goes, "if the only tool you have is the hammer, everything looks like a nail." This true of all practitioners. All of us must have an excellent knowledge of our field and an understanding of all areas that affect our field.

Surgery of the temporomandibular joint should never be the first choice of treatment for craniofacial pain/ TMD. According to the National Institue of Health, "the most common indication for TMJ surgery is previous joint surgery." Many patients have had multiple surgeries- one I met with 22. TMJ implants have been used with some horrendous results. This does not mean that it is not occasionally necessary (trauma, severe arthritic degeneration, etc.), but it should not be used as an initial treatment, even if your misinformed insurance company bases some decisions on their finacial health, not your physical health.

There are times when even the most conservative practitioner will reccomend arthrocentesis (irrigating for TMJ) or even arthroscopic surgery (microsurgery utilizing a tiny scope and instruments). Other procedures should be attempted prior to each procedure.

Dr. Larry L Tilley

Dr. Dylan E Holtman

Dentist-Calhoun
201 S Park Ave
Calhoun, GA 30701