Effective Treatment

Treatment of Pain From Occlusal Trauma

   If you have been to any other "TMJ sites" or visited a "TMJ office" you may have been told that this condition is very complex, expensive to treat, and that it may require many office visits. You may have read or been told that treatment will require fitting you with an expensive appliance that you wear between your teeth at night.  You also may have been told that the treatment involves hooking you up to a fancy machine that delivers electronic impulses to the TMJ muscles to calm them down.

    I am here to tell you that none of the above statements are accurate in our office. If we accept that all extracapsular TMJ disorders are due to clenching of muscles, in response to occlusal trauma then the treatment is to restore the balance and harmony between the teeth and to shut these muscular spasms off. It is neither expensive, or extensive and is often completed in one simple, painless visit.

    In all fairness, we do sometimes recommend an occlusal bite guard, but that is only when we cannot balance the occlusal contacts without damaging existing restorations or the teeth themselves.

    Please, do not take my word for this. Evidence-based medicine requires years of research and scientific study to prove that one treatment regimen is better than others.

    Fortunately for all of us a brilliant clinician and oral scientist in St. Petersburg, Florida did all the research and created a vast evidence-based strategy for all of us. His name is Dr. Peter Dawson.

 

The Dawson Method of Treating Occlusal Trauma...

     Like thousands of dedicated dentists, I am a Dawson trained therapist which means that I have spent countless hours at the Dawson Center for Advanced Dental Studies with Dr. Dawson and his team. Please click on the above link, where you can find out so much more about occlusal trauma than what I have listed here. Dr. Dawson is the author of "Evaluation, Diagnosis, and Treatment of Occlusal Problems." It is the authoritative text on this subject and I am proud to own an autographed copy.

     Here is what Dr. Dawson found out after decades of scientific evidence-based research and discovery.

    As mentioned earlier, the minute that the teeth contact something, the nerves in the ligament around the teeth and within the pulp detect it. We reflexively respond by immediately opening just enough to reduce the strain on both our closing muscles and on our teeth. This is how the body protects the teeth from the trauma or everyday occlusion - by releasing the big, powerful, closing muscles, and activating that little lateral pterygoid muscle as soon as we contact anything - like the feather which I mentioned earlier.  

    But here is the catch - The brain will not release the closing muscles until all the teeth contact at the same time with equal force while the jaw is rotating in that position of the TMJ called "centric relation."

 

The Key to it all - Centric Relation...

    It is the subject of centric relation that separates the Dawson trained therapists like myself from other TMJ schools of thought. But it is not up for discussion as far as I am concerned. Centric Relation is an anatomical, skeletal reality and its signifiance in proper occlusal function has been proven through detailed analysis of TMJ movement. It is the  only position of the TMJ where the bones of the joint are skeletally braced in such a way as to absorb the tremendous forces about to be placed on them when teeth contact teeth.

    The muscles that move the jaw and therefore the position of the teeth can create many different, variable positions between the upper and lower jaw, but the bones are constant. That is why centric relation is also a constant. That is why its importance in the story of occlusal balance and occlusal trauma is paramount - because centric relation is consistent, the appearance of TMJ related signs and symptoms, and the treatment of these conditions are also consistent with centric imbalance..

    When studying mandibular movement using sophisticated imaging, we find that the jaw is in centric relation when it is at rest. The lower teeth are just hanging there a few millimeters apart from the upper teeth. We are also in centric relation at the very instant just before we close our teeth together. In this way the bones absorb the full force of closure the hinge. Remember centric relation is a skeletally braced position, with the jaw being almost hingelike

    Once you leave centric relation, you are no longer in that skeletally braced, hingelike position. These positions would not be safe to exert the powerful forces of the closing muscles. So no matter where the lower jaw moves around to - left, right, forward, or back - we snap back into centric relation just before teeth come into contact. Again, this is not up for discussion. Anyone who refutes this has not studied the movements of the jaw in detail. Now lets repeat the phrase above and see what it means.

    The brain will not release the closing muscles until all the teeth contact at the same time with equal force while the jaw is rotating in a certain position of the TMJ called "centric relation."

    Therefore, as the lower jaw rotates in centric relation during closure, if even a single tooth strikes prematurely, before all the other teeth come into contact, the closing muscles will not release yet. They must all touch in centric relation for that to happen. However the opening muscle have also begun to contract in response to that first premature contact, and they won't turn off either until they all touch in centric relation..

    In order to achieve total contact of all the teeth you may  have to really squeeze on that interfering tooth or slide off of it. Either way it will displace the jaw out of its normal position, cause the uncoordinated muscle movement called clenching, and ultimately lead to TMJ disk displacement, pain, and dysfunction. And don't forget the facial pain associated with the closing muscles most commonly felt as headaches.

   Please trust me when I say that your TMJ/Facial pain is most likely due to an imbalance in the harmony between your teeth, your muscles and nerves, and your TMJ. How can I be so sure?

 

Balancing Teeth to Centric Relation...

    I am sure because every patient that I have ever examined that exhibited either facial pain associated with clenching, extracapsular pain in the TMJ, or both had a tooth that interfered with their centric balance. In other words when the jaw was positioned in proper centric relation, and the joint was loaded upward into the pad without eliciting pain, when we rotated the lower jaw upward we always found one tooth that hit first before all the others came into contact. This is your classic "centric interference."

    Furthermore, when all the teeth were then balanced in centric relation - in other words, they were all able to contact at the same time in this important position of the joint - then their clenching always stopped, every time. And the symptoms always go away, every time.

    The treatment is called an "occlusal adjustment" and it could not be simpler for the patient.

    First we dry the teeth, then gently cradle the jaw in centric relation for the patient and begin tapping the teeth together while a piece of "marking paper" is placed bewteen the upper and loewr teeth. This fancy carbon film will show exactly where your teeth are in contact. Once we know where that is, then we can methodically and carefully contour and relieve just those contact spots, continuing until all the teeth contact at the same time, in centric relation.

    Is this dangerous or damaging to your teeth? 

   All I can say is that nobody respects and admires the sanctity of your dental enamel more than I do. We remove no more than a fraction of a millimeter of this part of your tooth that is 2-3mm thick. I can say with all certainty that the damage from occlusal trauma is far more dangerous than a properly performed occlusal adjustment.

    Does it hurt to have this done?

    That is the beautiful part - enamel has no feeling! There are no nerves in enamel so touching it, even with a high speed, water-cooled dental handpiece, has no sensitivity whatsoever.

 

Biteguards revisited...

    Only a properly performed balancing of the occlusion to centric relation will create the environment that yields the comfort that comes with occlusal harmony. In fact if it is done improperly, or inadequately, symptoms will persist. But when it is acheived, centric balance provides harmony and comfort all the time, and rarely does this procedure have to be repeated.

   However, we may decide against  occlusal adjustment if we are concerned that balancing the teeth could cause ireperable harm to your teeth or any of your existing restorations. This would be the case if the teeth are really far from centric balance.

    In that case there are only two options to achieve the necessary centric balancing. One of them is comprehensive orthodontics to move the teeth into the proper centric balance. The other involves the fabrication of a plastic appliance that is fitted over the chewing surfaces of the teeth and then balanced that appliance, not the teeth, to centric relation. In other words all the balancing of the premature centric contacts can then be done on the plastic bite guard while leaving the actual teeth alone.

    So why is this not the preferred treatment?

   Because it only helps the patient when they are wearing the guard, which you cannot do unless you don't have to talk or eat. This type of guard is usually worn at night while sleeping, or during the day if the patient is in extreme pain. It is not definitive therapy, but one that provides some relief.But you better have centric balance in the guard, or it is just as bad as having an imbalanced natural occlusion.

    Do over the counter, store-bought bite guards work? The answer is usually no, because how can they be purchased balanced in centric relation?

    That being said, there is a simple bite guard that is used to relax the muscles of closure. It is very small and can be fitted by your dentist, positioned to sit just over the front teeth on the top or bottom. The theory there is that when the teeth contact just in the front, the muscles relax and stop clenching further. I have used them, but only when a patient refuses to do the more definitive treatment for either financial or philosophical reasons.

 

In Conclusion...

    As you can tell, this may appear to be a very complicated topic, but not really. Once you understand the anatomy, the cause of the condition, and its impact on the organs involved then understanding the benefits of treatment are better understood.

    And if you found this discussion enlightening,informative, and even reassuring you will enjoy the way in which I treat my patients in our unique dental setting. It takes time to teach, but I love it, and the rewards are equally substantial to myself and to my patients. Furthermore, you will find much more of this type of information in the "Learning Center" of this website

If you are experiencing any of these issues or symptoms, we encourage you to contact our office today to schedule an appointment.

 

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