I would like opinions on condition. My MRI findings are: moderate osteoarthritic change of the left temporomandibular joint with displacement of the articular disc anteriorly and failure to recapture/relocation of the disc upon mouth closing. I have many questions so please bear with me. First, my ENT doctor suggested surgery. My dentists feels he can give relief by fixing my bite with braces. I have a friend who had TMD problems years ago who was helped with series of splints to change her bite/jaw placement. Are there ways I can find which treatment has the best long term relief? Will braces or splints alone help long term? Is it true that if I choose surgery, I most likely will need a 2nd or 3rd surgery? If I choose both surgery and braces/splint therapy, which should be performed before the other? Finally, can you suggest specialists for these treatments in the Grand Rapids, Michigan area? Thank you for any ideas.
here is a government study on an ipod sized EMG unit, you can rent from a dentist, to diagnose the sleep disorder TMD (often called TMJ or TMJD). Once you have a real diagnosis, using proper sleep studies, you can stop TMD, non-invasively, and restore proper sleep patterns. EMG sleep studies are the only effective diagnostic.
Note that the national institute of dental health warns you to avoid the many bite changing splints, braces, orthotics, surgeries, etc., that so many dentists and doctors offer, particularly those who think that a bad bite, malocclusion, or misalignment causes TMD. Here is the NIH link:
Once you have gotten a positive diagnosis and stopped TMD, you might want to consider restorative/cosmetic dentistry, if you have harmed your teeth. It's nice to know that you won't grind right through all the $$ you spend on your teeth, because you have stopped the TMD. And since everyone bruxes periodically, you want to get a real diagnosis, before you start spending your $$ on TMD treatments.
Here is what the national institute of health reccomends on their site http://www.nidcr.nih.gov/OralHealth/Topics
I got relief when I stopped my TMD (clenching in my sleep), diagnosing it with EMG sleep studies, which are the most accurate, and then stopping it with CES biofeedback. You can rent an ipod sized unit from a dentist. Hope this helps.
Deepak is correct. TMJ disorders are different from person to person and should really be evaluated in person prior to receiving any advice. As he stated, what worked for your friend may not work for you.
My main suggestion would be to consider the least invasive approaches first, including chiropractic adjustment of your TMJ and acupuncture for TMJ pain control and musculature imbalance. If these safe, conservative approaches don't yield results, you can slowly progress to more invasive procedures like splints, braces, surgery, etc. Most TMJ sufferers can gain considerable relief or even a permanent fix from the more conservative approaches. If you jump straight to surgery, braces, etc... you are electing to receive procedures that can't really be 'undone', leaving you with potential scar tissue and other undesirable side effects that may complicate your problem even more. So start conservative/safe, and progress until you find something that works. Check out the TMJ pain link I have posted below. It will give you an idea of what chiropractic can do for your TMJ pain. Chiropractic adjustment of the temporomandibular joint is easy, safe and effective. Best of luck on your quest for a healthy TMJ!
natural health is correct that you should not try invasive treatments until you have tried non-invaisve treatments. The National Institute of Health recommends that you avoid bite changing, invasive treatments because they are contested - not proven to work.
If you can't get relief, rule out or diagnose and stop TMD bruxism, which can eventually cause TMJoint related pain. The most accurate and non-invasive way is to rent an ipod sized EMG unit to do home sleep studies. That way you are not buying a treatment that you might not even need, or could cause additional problems.
Thank you for giving me your background and the diagnoses that have given to you in the past inserting your temporomandibular joint problems. The treatment choices that you have been given seems to have just made your TMJ condition more confusing for you.
Orthodontics, surgery and invasive procedures are not the first treatment of choice. These are all considered Phase II nonreversible and invasive procedures. They are never the first treatment option for anybody.
Only a comprehensive examination and diagnosis with radiographs and diagnostic testing can give a competently trained TMJ specialist the information required in order to make a permanent solution work for you.
All ethical temporomandibular joint treatment begins with Phase I reversible and noninvasive treatment. If you don't like what you're first Dr. suggests, get a second opinion
Be careful not to accumulate too much radiation getting new x-rays, Cat scans, etc., from multiple doctors. Keep copies yourself, and make sure you bring them to new doctors, because they know how to gauge, but you need to show them what you've already done. Otherwise they are in the dark and just order new sets of everything.
If your TMJoint related pain is caused by TMD bruxism, you should use the only accepted, effective diagnositc, EMG sleep studies, to rule it out, or diagnose and stop. Before trying out bite changing treatments that the NIH advises against, since they are contested (not proven to work).
While everyone will advise to stay away from certain treatments, there is a lot of mis-information and mis direction in a couple of posts. Noninvasive treatments are always first choice, but there is very little evidence that biofeedback is helpful to stop sleep bruxism. That is a huge leap of faith away from what the studies show when testing these devices, and the studies themselves are not well done in the first place. It is very obvious that the poster in this case has a vested interest in the treatment. Buyer beware......
The national institute of health I linked to above advises against contested, invasive treatments. I have no vested interest in any treatments, nor products. I am just a person with wrecked TMJoints (multiple severe dislocations from sports and car accidents, and chronic bruxism). I wouldn't be surprised to learn that you are a doctor or dentist who is invested in treatments for TMJoint related pain. In any case, I am not, nor am I a salesman, not am I vested in any way, other than experience and results.
I spent a mansion-worth of dollars, trying every invasive, bite changing, therapeutic treatment for TMJ related pain, that various dentists, TMJ specialist dentists, doctors and pain specialists could think up. This included arthroscopic surgeries (Mayo is at least honest enough to state that titanium replacment often gives NO pain relief), Botox (causes long term jaw bone density reduction), progressive splints, NTI devices, many drugs, physical etc. therapies, etc. etc. A very few of them temporarily interrupted my TMD bruxism, and temporarily reduced my levels of pain. Most made it worse or did nothing but spend my life savings. The worst was getting temporary results, and temporary hope.
I knew I was a bruxer, and found that the slimmest, slightly flexible bite guard, made by my dentist who also bruxes, really reduced harm to my teeth and my dental work. It also did not increase leverage on my ruined TMJoints, nor TMJoint area pain, like some of the fancy splints did.
Then I learned that venerable, proven, non-invasive EMG sleep studies are the most effective diagnostic for TMD bruxism. And EMG sleep studies will also track your reduction in bruxism. And it meant I could finally manage my pain levels and have a life again.
There is nothing contested about diagnosing TMD bruxism with EMG. In fact, the original sleep centers that tested for apnea, like Stanford's, used to include an electrode to the temporal muscle. One thing they were trying to do was see if there is a significant relationship between chronic TMD sleep bruxism and apnea, which I don't think anyone ever proved.
I just wish I had all the money I spent on expensive, invasive TMJD treatments that ASSUME a diagnosis, based upon structural analyses.
If bruxism is not causing your TMJoint related pain, EMG won't help you at all, except to rule out chronic sleep bruxism as a cause of your TMJoint related problems. Ruling out a diagnosis is a time tested way to save a lot of time, pain, side effects, and money. You can rent from a dentist now (there's a list of dentists in various states).
There are unfortunately still many pain conditions, that you STILL have to diagnose by trying on treatments, then diagnosing by results, like hereditary migraine, for example. But TMD bruxism is no longer on this list. And TMD bruxism can cause a lot of TMJoint related problems.
I expect that sleep studies for TMD bruxism will become eventually covered, like sleep studies for apnea. In any case, it's non-invasive and tracks what's going on, instead of making assumptions. And a lot cheaper and safer than invasive treatments.
You are correct that exactly how CES biofeedback works on TMD bruxism is not yet fully documented with enough double blind studies for the kind of agreement that EMG has. But Electromylography is completely understood as effective, both diagnostically, and also for effectively monitoring reduction in chronic sleep bruxism.
So it would be tragic if anyone conflates questions about biofeedback or CES with EMG. And non-invasive CES does not interrupt normal restorative sleep patterns.
I just see no benefit to patients in sowing doubt about the NIH reccomendations, or in EMG as a diagnostic or monitoring tool.
Most studies show that sleep bruxism ( not the term "TMD Bruxism" ) is very common in the general population, whether it be centric clenching, latero-protrusive grinding, or tapping of the teeth. As a matter of fact, almost all people do it to some degree at some time during their normal sleep cycles. EMG recordings of muscle activity are just that...recordings of muscle activity. There has never been a correlation between muscle activity and pain...at least a dose - related correlation. The worse sleep bruxers are NOT the ones who have the most pain and dysfunction associated with their TMJ's. And interfering with temporalis activity at night ( which has not been proven to stop sleep bruxism ) has not been shown to be effective in managing TMD's....the studies on units like Grindcare DO NOT show that. You are extrapolating data to fit with what you THINK is going on. This is due to a need for humans to KNOW, which is the process of "Argument from Ignorance". If it worked for you, GREAT. But do not make unsubstantiated claims and huge "leaps of faith" as to what is going on based on the knowledge we have. If you do, then people will end up spending even more money on treatments that are not effective for them. Remember, 75% of people will improve no matter WHAT treatment you do on them....
What's the problem w/ EMG sleep studies, & what are you sell
Yep, everyone bruxes sometimes. You must not have seen I already provided the National Institute of Health link, that most people will get better doing the least possible. I have also agreed with you that how CES biofeedback works, and how well, is not yet studied enough for consensus.
Why add to your false shilling accusation that I am extrapolating, making leaps of faith, and arguing from ignorance? Your jargon sounds invested, to me.
I think your leap from "75% of people will improve no matter WHAT treatment you do on them..." to accusing me of recommending people waste money, is a dis-service to patients who want to use EMG sleep studies, as a cost effective diagnostic and monitoring tool.
My whole point is that BECAUSE chronic TMD bruxism can be temporarily interrupted, by many treatments, we need EFFECTIVE diagnostic and monitoring tools like EMG, that also monitor if you have improved or not. Most treatments assume diagnoses based on analysing structures, not on sleep studies. And these unproven treatments are expensive, providing false hope, from temporary interruption. They can also cause long term damage, and new or worse problems, like leveraging more pressure onto TMJoints, jaw bone density loss from Botox, etc.
Dentists renting EMG recorders out, are NOT going to make big revenue off venerable EMG sleep studies, which units like Grindcare's make easy. On the other hand, the neuromuscular, progressive splint, and bite changing specialists are not only expensive, but unproven.
Your post implies that ruling out severe, chronic bruxism, with effective, non-invasive EMG sleep studies, or EMG monitoring to see if bruxism reduces, is bad. Why? What treatments do you sell?
I am not recommending ANY treatment at all. I prefer to diagnose. I can tell if someone is grinding their teeth by looking at the teeth...AND I can tell HOW they brux. I can also ascertain which muscles are involved, and what amount of damage has been done to the TMJ through a careful examination. I can also look to see if any ancillary tissues are involved. I spend a lot of time with people asking a lot of questions about the history of their problem, and doing very thorough examinations. I take into account their psychological profile, and whether the autonomic system is now involved.
You keep saying "effective, non-invasive EMG sleep studies" and say that EMG monitoring tells us whether bruxism has decreased. HOW ???? It is measuring temporalis activity ONLY !!! You are EXTRAPOLATING that data to try to measure something it does not measure. Temporalis activity DOES NOT measure the amount of bruxism, so it is not an "effective" study to tell us anything other than temporalis activity. What about the masseters ? The medial Pterygoids ? The splenius capitus, the semispinalis capitus ???? What about the lateral pterygoid ??? PLus, the EMG activity you are measuring on the temporalis is the anterior temporal is, not the middle or posterior temporalis.....
If you are wondering...I DO NOT change occlusions. You are entirely correct...they are NOT effective treatment modalities. So far, neither is Grindcare.
ok, you falsely accuse me of selling something, and now you say home sleep studies, using EMG like Grindcare's, don't measure or monitor bruxism.
You say that you "prefer to diagnose." Any dentist can see wear from bruxism. And studies show that Grindcare compares well to sleep labs that add audio, video and analysis to EMG, for diagnosing bruxism. Yet this effective, non-invasive diagnostic and monitoring tool is suspect to you.
When I separate your conflation of Grindcare's CES with unproveen, contested, invasive bite changing therapies, you are saying CES is an unproven treatment. Grindcare has the integrity to include on their website the NYU study of 9 patients for 2 weeks, which concludes that their study is inconclusive. You may be referring to this study?
You may help get bad treatments exposed, or advance general knowledge of good research. But it's hard to tell, from your false personal accusations, avoidance and conflation of research, and your jargon. Still don't know what treatments you sell, but good luck.
The research Grindcare cites are from Jadidi et al, which studied 14 people, was not double blinded, nor placebo controlled. They found that temporalis activity decreased over the short length of the study, and that sleep patterns were not affected. This is a good start to commence proper studies to look at the long term benefits of the treatment, but the data is not there ... YET ! They did NOT study sleep bruxism, they studied anterior temporalis activity. There was no conclusion that sleep bruxism was reduced, because even Jadidi realizes that the study is inconclusive in that regard. The Grindcare people are extrapolating the data to suit their needs.
Please do not accuse ME of using jargon... you are the one using the "made up" term "TMD bruxism". There is no such entity. The terms are sleep and awake bruxism, which are an evolution of nocturnal and diurnal bruxism. ( these were changed to reflect the fact that some people sleep during the day and are awake during the night). Sleep bruxism is a centrally-mediated event, while awake bruxism is a "habit", if you will. Sleep bruxism, by itself, is generally not a problem. In the presence of modifying factors, it can be. Protective appliances can be very effective in reducing the force vectors and intensity of the sleep bruxism activity, and seem to work long term. Low dose anti-depressants will also reduce sleep bruxism activity, but only in the short term. Please note that appliances that change the bite have not been proven effective, and I do not condone their use. Other types of appliances (that do not change the bite) are generally very effective, but may ned to be augmented with injection therapy, iontophoresis, laser therapy or pharmacotherapy. TMD is often misdiagnosed, so that many orofacial pains which do not originate in the TMJ's or masticatory muscles are termed " TMD's". Proper diagnosis is the key, and that involves knowing what structures are involved, how they are involved, and why they are involved.
I'm glad Grindcare helped you, but how do you know that the cumulative effect of all your other treatments helped get you to the point where Grindcare was able to put you "over the top" ?? I am never smug enough to say my treatment "cured" a patient...my treatments are only able to help the patient heal or adapt themselves so that their pain is managed at this point. If and when Grindcare gets the power of proper scientific study behind it, and it proves effective, then I will use it. But patients are subjected to enough unproven treatments as it is, and adding one more at this point would just be wrong.
So you still don't explain your claim that EMG sleep studies couldn't possibly be the effective diagnostic and monitoring tool for bruxism, nor upon what you base your preference for diagnosing instead. This is pretty amazing, since you are selling treatments.
Now you add a baseless claim that Grindcare is extrapolating data to nefarious ends, to me being a shill, smug, and touting cures, and having vested interests. I'll just leave you lie.
Obviously you know nothing about the treatment of orofacial pain...there are many TMD's where sleep bruxism is not the cause, or even a major contributing factor. EMG studies are NOT the gold standard for diagnosis of sleep bruxism, and I have no clue where you got the idea that they are.
Any treatment without a diagnosis is malpractice...pure and simple. Would you let anyone treat your back pain or shoulder pain without knowing what it was ? How about abdominal pain ? Do you treat first and then try a lot of different treatments until one works ? Of course not.... you diagnose the disease. Sleep bruxism is not a disease, so it does not have to be diagnosed. And depending on how you monitor with EMG's, you will get many false positives and false negatives as to when people are bruxing. Show me a study that shows that sleep bruxism is reduced, please. I am just reading the literature with an unbiased eye. I do not make proclamations or leaps of faith based on what the studies actually show. I have seen no studies where the authors have concluded that sleep bruxism is reduced.
Just as an aside, this is a from a 2008 paper ( Svensson, Jadidi, Arima, Baad-Hanson & Sessle) which was co-authored by Jadidi, who did most of the work on the temporalis EMG in the same year.
"... there was a significant change in EMG events per hour of sleep, with a reduction of approximately 53% in sessions with stimulation in contrast to 31% without stimulation. These results raise the question whether learning or conditioning effects could take place over time. However, further studies are required to determine the long-term effect and any possible learning effects of biofeedback on patients with sleep bruxism will require further studies. In the Jadidi et al study, there were, however, no significant effects on craniofacial pain parameters...."
Two important things to note .... 1) there was an effect of reducing muscle activity by doing nothing at all....just putting the EMG pads on reduced events by 31 %
and 2) the fact that further study is required so as to determine the effect on sleep bruxism.
Also note that there was NO reduction in pain levels ....which the authors explain by "the dissociation between levels of muscular activity and craniofacial pain."
So straight from the horses mouth ..... no conclusions about the use of a device like Grindcare for the treatment of TMD or sleep bruxism...... so , yes, there was an extrapolation of the conclusion to suit the devices' manufacturer. Might it work ? Yes...... I certainly hope so. We need more PROVEN remedies, especially ones that are non-invasive. This would certainly be a welcome addition if can be shown to be effective.
"Obviously you know nothing..." "straight from the horse mouth" What ARE you selling!
Your effort to imply that home EMG sleep studies are NOT THE most effective diagnostic, and THE most effective treatment monitoring tool is getting impressive.
People should use it to rule out, or diagnose, sleep bruxism (often diagnosed as TMJ, TMJD, malocclusion, or various structural abnormalities that may be completely irrelevant). Before they start on the treatment-as-diagnostic bandwagon.
For the nth time, why are you still expounding upon inconclusive CES studies as though it says anything WHATSOEVER about the effectiveness of home EMG sleep studies, for both diagnosis and treatment monitoring of sleep bruxism?
As you can see, I"M NOT SELLING ANYTHING...just offering people the correct information on a product you are pushing .... before they get a correct diagnosis. I am offering studies, which in medicine, and science in general, are the means by which to assess a new treatment and / or technology. Your Grindcare is ineffective for diagnosing anything other than anterior temporalis muscle activity.
From Lavigne 2011 ( Gilles Lavigne is considered the foremost expert in the field of sleep and sleep movement disorders such as sleep bruxism)
Confirmation of an unusual oromandibular motor
activity can be made using several tools: (1) sound
recording (e.g., a voice-activated recorder placed next
to the pillow at bedtime); (2) video and sound home
recording (focus on head and face) with a black light
in the room; (3) portable EMG recording with video
and sound at home; (4) laboratory recordings with
audio and video recordings, EMG recording of at least
one masseter muscle plus electroencephalogram, leg,
EMG, or sensor and respiratory activity sensors to rule
out concomitant sleep disorders such as periodic limb
movement during sleep, apnea/snoring, insomnia/pain,
sleep epilepsy/tooth tapping. Be aware that, in the
absence of audio-video recordings, specific assessment
of jaw muscle EMG is weak as approximately
30% of oromotor activities during sleep are not
specific to sleep bruxism (Dutra et al., 2009).
Anterior temporalis activity is not used at all, and EMG's are generally using the masseter. Your Grindcare, as of this moment, diagnoses nothing, nor monitors sleep bruxism ( see the last line of the study provided). If it does, please provide me with the research.
Oh...and sleep bruxism is categorized as a sleep movement disorder or a parasomnia. It is NOT TMJ, TMJD, or TMD. Those who brux the most have a lower incidence of TMD than those with very little evidence of sleep bruxism. Malocclusion is a totally unrelated subject and would best be described as a modifier when talking about TMD. Structure, as you say, actually has very little to do with most TMD's.
Ha, ha. I am not selling anything, but am willing to bet you make your money as a dentist, neuromuscular 'specialist,' TMJD expert, or somesuch.
Of course Lavigne is correct that doing EMG readings of the masseters can be totall misleading. As usual, you pretend that your selected study disproves EMG to the temporalis as a diagnostic and monitoring tool, when it doesn't. You assert it now, yourself, explicitly, which is at least on record.
Put the pad of your index finger on your temple. Clench or grind your teeth. Feel the temporalis muscle contract.
I am sure you will talk about how the temporalis muscle extends way past the hairline, and maybe come up with more studies, that talk about something different you can try to continue to conflate to support your mere assertion. And there are plenty of outdated studies too. Have at it.
But I think you have finally done an excellent job of conflating irrelevant studies, multiple times, to try to disprove something that is pretty much accepted.
Put the pad of your finger on the temple ( the anterior temporalis) and open and close your mouth WITHOUT touching your teeth together. Feel the contraction???? This is the same contraction that happens with Rhythmic Masticatory Muscle Activity (RMMA) which is a NORMAL part of the sleep cycle.
That is what the Grindcare will measure as signal.... and will therefore give a false positive for a bruxism event. RMMA's occur very often during sleep, but there is no effect since the teeth don't actually touch during the majority of them.
Whether you like it or not, scientific study is important. I have read and presented you with studies that conclude there is no link between anterior temporalis contraction and sleep bruxism, nor sleep bruxism and muscle pain. You may think them irrelevant, but the scientific community does not. If you could provide research papers to back your point, please feel free.
As for Lavigne, that paragraph was from the latest book he wrote, which cited hundreds of studies. None of them backed your assertions. So I guess we should take your word for it, rather than the word of someone who has spent 25 years ( at least ) studying sleep and pain ? I find that interesting, to say the least.
"Ask a Doctor" questions are answered by certified physicians and other medical professionals.
For more information about experts participating in the "Ask a Doctor" Network, please visit our
medical experts page.
You may also visit our TMJ , for moderated patient to patient support and information.
The information provided on eHealth Forum is designed to improve, not replace, the relationship between a patient and his/her own physician.
Personal consultation(s) with a qualified medical professional is the proper means for diagnosing any medical condition.