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TMJ Disorder stuff ? (Page 1)

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Hi, I'm 20 years old now, and ever since I was in middle school (about 11-13 years old) I always heard talk about "TMJ" when I went to the dentist, but nothing was ever done, nothing was ever explained to me.
Now I'm an adult, I go to the dentist on my own, and my dentist got me a NTI TSS thing for my mouth. Today he gave it to me and told me how to use it, clean it, store it, take it off, and blah blah blah.
I get home and I realize, I don't really know anything about TMJ Disorder, except for my jaw pops and clicks and hurts and can't always open all the way, and now I have this plastic thing to snap onto my bottom teeth at night, and that feels funny.

I grind my teeth at night, or so I've been told (I've never caught myself in the act, I'm unconscious! lol! but I wake up with wiggly teeth, always have, as far back as I can remember... since back in elementary school, and I was told recently that that is from bruxism.) I also notice that through out the day I clench my jaw with out intending to, like it just happens. Is that the TMJ Disorder too?

I really know nothing. I Googled "What is TMJ Disorder" and it says it's a disorder of the temporomandibular joint. Well thank you Google, I couldn't get that far on my own Razz

Anyways, I was hoping for some help and advice and such from people that actually know what all this is. Thanks! sunny (this little smiley sun is too cute!! lol)
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replied September 17th, 2010
im not sure what TMJ is, but i have very similar symptoms tbat are sjmilar to yours - the clicking/hurting jaw, grinding my teeth and clenching my jaw without intentionally doing so.... i just wanted you to know you're not alone. Smile
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replied November 10th, 2010
Heyscoobie,

Would you recommend wearing an NTI splint in someone who has TMJ dysfunction, such as displaced discs? I understand the purpose of the NTI is to prevent clenching at night and therefore reduce the risks of injury to the TMJ in the first place, but if you already have displaced discs, is it likely to make the dysfunction any worse, or is an NTI alone likely to treat the TMJ dysfunction? It’s probably what the person who started this thread would really like to know.
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replied November 14th, 2010
Interesting dialog between two dentists from two different occlusion camps. First, understand no bite, be it neuromuscular or centric relation will stop a patient from clenching or bruxing. The question that must be answered is it the bite that is causing the problem? The picture from a Google search is a perfect example that it's not the bite, putting a pencil between the teeth and not clenching will work. Each camp has its own beliefs, and both can be flawed. For example 2netta posted pictures of an NTI that resulted in an "open bite", my observation is the patient always had an open bite, if the appliance caused it, why are teeth that aren't part of the NTI also part of the open bite?
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replied November 14th, 2010
Experienced User
Just so I understand correctly, Netta

It is OK to permanently change the occlusion to the NM position with an LVI orthotic.

It is NOT OK to permanently change the occlusion to MSP with an NTI-type orthotic.

Interesting.

Also, do you recommend that non-LVI trained dentists NOT use LVI-type orthotics ?
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replied November 15th, 2010
Experienced User
2netta wrote:
Doctors and fellow members of the forum, I posted pictures of my patient's study models with her NTI in place to caution PATIENTS who are using one to be sure to wear according to the instructions given to you by your Dentist and not wear it longer than instructed because there are serious ramifications.

My patient came to see me because her headaches returned and as you can see from the photos that I posted, her posterior teeth were now touching, which allowed the temporalis muscles to contract again and cause pain. In addition, she was evaluated for sleep apnea (which she does have).

Again, to reiterate, the purpose of my post was for people posting on this forum that may have or plan to get, an NTI. Simply...do not wear it longer than you are supposed to and stay in touch with your dentist if you notice any changes in your bite in the front of your mouth.


Great advice 2netta !! This is the main problem I have with NTI... it is too readily available for almost any dentist to make, and , even though the website is full of information, I am afraid many dentists will get these and use them in cases where they shouldn't. There is a very specific protocol to follow when using any type of partial coverage appliance.
There are so many problems with this appliance in this patient, I would believe the dentist was not really aware of the consequences of putting one in. The open bite is generally NOT from teeth intruding, but rather a seating of the condyle up and back combined with a cranial rotation. You will notice that some of the teeth that are open do not even contact the appliance, so intrusion is not the culprit.

Make sure your dentist knows what they are doing before getting ANY type of appliance. All CR type appliances can seat the joints ( which is actually a good thing, as it means the lateral pterygoid muscle is now relaxed ), but the NTI seems to make it happen faster.
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replied November 15th, 2010
2netta wrote:
Doctors and fellow members of the forum, I posted pictures of my patient's study models with her NTI in place to caution PATIENTS who are using one to be sure to wear according to the instructions given to you by your Dentist and not wear it longer than instructed because there are serious ramifications.

My patient came to see me because her headaches returned and as you can see from the photos that I posted, her posterior teeth were now touching, which allowed the temporalis muscles to contract again and cause pain. In addition, she was evaluated for sleep apnea (which she does have).

Again, to reiterate, the purpose of my post was for people posting on this forum that may have or plan to get, an NTI. Simply...do not wear it longer than you are supposed to and stay in touch with your dentist if you notice any changes in your bite in the front of your mouth.


Patient has sleep apena. OK, so what keeps her from clenching in a NM position? I assume she has to occlude sometime. It's not the occlusion, it's the clenching on the occlusion that is the problem. Look to sleep studies, patients especially apena patients clench. Bite design will not prevent this activity, period.

If you are a patient who has TMJ and you believe you might have apena, I strongly recommend that you see an MD for a sleep study as well as your dentist.
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replied November 15th, 2010
Experienced User
heyscoobie wrote:
The NTI is FDA Approved for Migraine Pain Prevention

A device to be used in the prophylactic treatment of medically diagnosed migraine pain as well as migraine associated tension-type headaches, by reducing their signs and symptoms through reduction of trigeminally innervated muscular activity--- excessive occluding of the teeth.

The NTI is FDA Approved for the prevention of bruxism and TMJ syndrome through reduction of trigeminally innervated muscular activity ---excessive occluding of the teeth.


Four factors dictate the presenting signs and symptoms:
--Intensity of the occluding;
--Frequency of the occluding;
--Duration of the occluding;
--Degree of condylar translation and direction of the pull on the condyle by the lateral pterygoid during the occluding event .

Of those four factors, the most significant is the intensity of the event. The full contact occlusal splint cannot reduce the intensity of nocturnal clenching, in fact, it allows clenching to exceed voluntary maximum.


There are other designs here that will provide for minimal muscle contraction and lessen the chances of condylar seating and cranial rotation. Since the patient has OSA, that trumps the TMD symptoms for now. In some of these cases, a combination appliance ( MAS with anterior discluder ) works very well to both treat the OSA and the joint. I'd be keeping an eye on the joint in these cases for sure , though !!!
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replied November 15th, 2010
Hounder wrote:

There are other designs here that will provide for minimal muscle contraction and lessen the chances of condylar seating and cranial rotation. Since the patient has OSA, that trumps the TMD symptoms for now. In some of these cases, a combination appliance ( MAS with anterior discluder ) works very well to both treat the OSA and the joint. I'd be keeping an eye on the joint in these cases for sure , though !!!


X's 2
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replied November 15th, 2010
Experienced User
Hey scoobie..... I like to use an anterior repositioning appliance with an anterior discluding element. It's a dual arch appliance that forces the mandible forward , but only the anterior portion is in occlusion.

SomnoDent has a MAS that you can add the DE in order to separate the posteriors. It's my appliance of choice for OSA as long as patient's don't have the majority of their apneic episodes during REM. I will still use the SomnoDent, but with further modifications, or move to a TAP.
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replied November 16th, 2010
Experienced User
2netta wrote:
Another point to look at if a Dentist fits a patient with an oral appliance, whatever the design, re-testing regarding the OSA status is paramount. Is the appliance helping? Is it helping ENOUGH?

Also, with regards to chew cycle interferences, this is the type of movement that is destructive and causes patients to continue with bruxism type movements (as opposed to clenching) in an attempt to remove the interference, over taxing the muscles and in some cases causing very severe headache pain.


Could you explain "chew cycle interferences " ? Are you referring to when a patient chews food, or just the actual movements ( latero-protrusive ) we see during the parafunctional activity ?
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replied November 16th, 2010
Experienced User
2netta wrote:
Hounder

"All CR type appliances can seat the joints ( which is actually a good thing, as it means the lateral pterygoid muscle is now relaxed ), but the NTI seems to make it happen faster."

Do you really want to seat the joints here???




the lateral ptyergoid is the least of her concerns...what about all of her other muscles?


C'mon, Netta .... that is a structurally altered TMJ. There are always exceptions to every rule and CR ( or MSP ) is limited to a structurally healthy TMJ. Personally, I don't use CR as it is more of a restorative reference point rather than a therapeutic position. Please let's compare apples to apples from now on.
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replied November 16th, 2010
Experienced User
2netta wrote:
Sorry Hounder, you are just going to have to research chew cycles on your own! Smile

We Neuromuscular Dentists are keen on making sure that we deal with them..


OK... but you got some 'splainin' to do about the body trying to get rid of interferences as the reason for grinding...... that is totally unfounded as the first event in a parafunctional activity is depressor contraction from the rest state ( teeth are already apart), followed by a lot of elevator activity before the teeth even contact.

Tell me what these interferences are interfering with ?
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replied November 16th, 2010
Oops, double post.....
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replied November 16th, 2010
2netta wrote:
Hounder, I know what I know and I use it in my office everyday. If you don't want to learn about it,want to critcize it, joke about it, feel superior about it...it is your patient's loss...and that is certainly your choice. Smile


Since this is a site for non-dentists looking for answers and possible solutions to their problems we need to get back to basics. First, over 90% of the population have teeth that meet differently when biting together than where they meet in whatever is their ideal TMJ location. Does that mean that 90% of the population has TMJ? The answer is of course, no.

Over the last 4 decades dentistry has been looking to help those who have TMJ pain, and for a while it was believed that the way teeth came together and apart could cause clenching and grinding that resulted in the pain. Fast forward to today, with the advent of sleep studies we now know these damaging muscle activities have little to do with the bite or the location of the joint. Bruxism is an exaggerated form of oromotor activity associated with sleep micro-arousal.

Neuromuscular dentists point to Jankelson's studies, which have been called into question on too many levels to accept his findings and recommendations. Equally questionable are the advocates of Centric Relation dentistry, Pankey promotes ideas that have also been seriously questioned. What I am saying that one should question any theory that was disproved years ago, only to be re-packaged into much more marketable form.

Pain is much more complex than where the teeth and joints are. One final point, the literature is in agreement that Mandibular repositioning splints made to an increase of vertical dimension of occlusion (in CR or NM downward and forward), have the universal effect of decreasing muscle activity and symptoms, which may decrease pain for the short term.
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replied November 16th, 2010
Experienced User
2netta wrote:
Hounder, I know what I know and I use it in my office everyday. If you don't want to learn about it,want to critcize it, joke about it, feel superior about it...it is your patient's loss...and that is certainly your choice. Smile


I'd love to learn about the chew cycle. Is it in the open source literature or is it stashed away somewhere in the secret Templar lair in Las Vegas ? looking
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replied November 17th, 2010
Experienced User
ocluzen ... well stated and a very good overview of where we are in the field of TMD today.

I would like to add that splints don't even need to be in CR or the "NM Zone", but can be in the habitual bite position, made to a phonetic bite, etc., and still work to relieve pain. Instead of trying to fit everything that we see into an NM or CR box, we would be much better to ask, " Why do these other modalities work ?" Instead of steadfastly touting our successes,( which every "camp" can do), we should always be asking, " Why did my treatment philosophy fail in this particular case ?" The truth will be found there.
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replied November 17th, 2010
Experienced User
My Cr training in dental school , and subsequent to dental school was for a restorative starting point, which Pankey et al moved to the ideal joint position to treat TMD. One word changed my whole philosophy.

"WHEN ?"

It would be advantageous for everyone who treats to a specific joint position to ask this question. WHEN ??

( When is the joint in this position during my patient's normal activities ?)

BTW, you do realize that the lateral pterygoid is NOT relaxed in the NM zone/ position. Why is that not a concern for NM dentists ?
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replied November 17th, 2010
2netta wrote:
Hounder, I am going to post the same reply that I just did on another thread in response to you.

"Hounder, I know that you feel that you and your methods are superior to anything that the rest of us have to offer from a Neuromuscular perspective.
Why not tone down your rhetoric and consider that when you state that there is "zero evidence", "quite preposterous" or "made up term with zero credibility".

I am your colleague and I have been practicing for over 30 years. I pride myself on being on the cutting edge and I have devoted a lot of time, energy, and money to continue with my education well above the minimal requirements to retain my state licensure.

Both you and I were trained in CR (Centric Relation) theory and practice in Dental School. I began my studies back in 1977. I have opted to pursue a different path than that CR philosphy because of what I can provide for my patients. Allow me to again stress the "what I can provide".

Neuromuscular Dental treatment has been around since the 60's and the pioneers had to be quite steadfast in order to stay the course against many naysayers...like yourself.


The scientific articles in support of NM principles are well published and readily available. Also, the journal "Cranio" publishes many articles monthly on cases that are documented being treated Neuromuscularly with references. That might be a good place to start your research quest.

Best Wishes on your journey!


I'm going to make this a simple as possible, if you believe that its the parafunctional (grinding and bruxing) that causes pain, prove to me this is caused by the jaw position and/or the bite. Again, we now have sleep studies to prove that it is not the bite that causes patients to clench.

I assume we can agree that the assumption that its the clenching that causes the pain. If so, then we need to get the back teeth out of the way, doesn't matter which occlusal camp you are in.

Tell me what you want for a bruxing patient in pain...........
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replied November 17th, 2010
2netta wrote:
"Again, we now have sleep studies to prove that it is not the bite that causes patients to clench."

Yes, it is likely Obstructive Sleep Apnea!


Hounder stated "BTW, you do realize that the lateral pterygoid is NOT relaxed in the NM zone/ position. Why is that not a concern for NM dentists ?"

This is an old red herring that is repeated over and over again by those that would like to discredit Neuromuscular Dentistry. Since the Ultra Low frequency (ULF) tensing that we use, has effects that are CENTRALLY mediated by the neural stimulation of the Trigeminal and Facial nerves. This neural mediation allows the muscle spindles to elongate as they relax.
Indeed the Lateral Ptyergoid is relaxed.

Here are some references and there are many more that have validated these. FUJI H & MITANI H 1973-J DENT
RES.1973 SEPT-OCT 52(5);1046-50
FUJI H -J
ORAL.REHABIL.1977JUL;4(3):291-303

Repeating a falsehood over and over and over again does not make it true.



Let's look at muscle physiology, the lateral pterygoid has very few spindle fibers. And the lateral pterygoid is not under myotatic reflex control.

Because TENS does not act centrally (I'm not going to bore anyone here, but if you want the references PM me, and these references can easily be found and abstracted on PubMed), it acts upon the elevators to lengthen them. But without equivalent spindle fibers, the lateral pterygoid must be shortened. If it wasn’t, the condyle would not be down the eminence. It seems impossible that the LP can be “relaxed” if it has to remain contracted to keep the condyle down the eminence.

I'd love to read your references, but I could not find them. If you have them could you PM them to me?

I'd like your thoughts on Barry Glassman's video.......
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