Severe pain or severe damage to TMD should be a referral Orofacial Pain Specialist for your patients.

The critical piece information to orthodondist, prosthodontist, periodontist, and general dentistry is the loss bone in TMD can & will affect the occlusion.

Symptoms of Severe Damage TMD include:

1. Severe pain jaw joint
2. Boney changes to condyle
3. Bone on bone in joint
4. Moderate to severe pain
5. Gravelly-scraping-crunch sound
6. Inadequate disc space
7. Image required: Cone Beam CT, CT head, MRI TMD
8. Coarse crepitus
9. Bite change-asymmetry-deviation
10. Boney changes fossa

Progression of damage for osteoarthritis

1. Sup. Lateral Pterygoid Muscle over recruited from multiple sources
2. Pull-tear-stretch lateral ligament of disc
3. Partially displaced disc (DD) to Complete DD to Osteoarthritis
4. Chewing forces on retrodiscal tissue damage-shred-tear tissue
5. Perforation retrodiscal tissue
6. Bone on bone

Hints of severe damage-history include:

1. Bite changes
2. Facial asymmetry
3. Atypical Toothache
4. Atypical Earache
5. Temple Headache
6. Deviation & limited opening 

A general dentist should never accept the challenge to treat severe damage TMD cases. Even if the patient is long standing pillar of community who demands you treat him/her.

1. Ask him/her question. "Would you demand of your PCP to treat severe arthritis of knee?"
2. Inform him/her that a dentist gifted w/ dental conditions, but orofacial pain specialist treats muscle & joint cases

Goals Chewing system Orthopedics in OA:

1. Stop bone turn over
2. Promote healing
3. Confirm TMD stability

Confirm Stability of Chewing system:

1. Successful completion of chewing system orthopedics
2. 3 to 6 months adjust orthotic w/ little or no change bite
3. No pain flares for 3-6 months

CHEWING SYSTEM ORTHOPEDICS TEAM:

1. Patient
2. Chewing system orthopedist
3. Physical therapist
4. Biofeedback

Secondary symptoms: OA in TMD

1. Posterior teeth hit harder on one side = bone loss in one TMD cause loading molars
2. Pain 2^nd molar = bone loss in 1 condyle causes loading molars
3. Progressive anterior open bite = bone loss both condyles
4. Asymmetry-chin midline off, smile line canted, lower front teeth slanted
5. Coarse crepitus: gravelly sounds in jaw joint

OA Confusions

1. Mild Pain even with Bone Loss
2. Occlusal Problem coming from bone loss in TMD
3. Pain Tooth coming from loading tooth by Bone Loss TMD
4. Arthritis in young women under 30
5. Mild creptius in severely damage
6. Anterior Open Bite when bilateral bone loss TMD
7. Surgery is not usually necessary

REFFERRAL OROFACIAL SPECIALIST:

1. Bone loss in condyle must be stopped before any restorative dentistry is performed
2. TMD stability must be established before Occlusion can be restored
3. How can orthodontist or prosthodontist diagnose unstable bite
   • Deviation opening-Smile Line discrepancies-range motion differences-posterior open bite
   • Difficulty w/ occlusion, need for equilibration, occlusal adjustments fail, difficulty with crowns, difficulty implants, crowns break off
4. Why is bone loss in TMD a problem:
   • Placement of mountains and valleys of teeth is compromise
   • Accuracy of occlusion is wasted
   • Loss of investment on by patient
   • Ongoing occlusal discomfort
   • Bite is ever changing

YOUR DISCOVERY IN TX PROCESS

1. High pain threshold (hides bone loss pain)
2. Bone loss 1 condyle causes shortening table leg-pivots to that side
3. Rapid Bone loss sets up loading second molar
4. OA is not always an old age disease (30 yr old women can have OA)  
5. Bad health habits are fuel for chronic damage
6. Grinding-clenching hidden & progressively destructive to joint
7. Bite changes cannot be fixed by equilibration or occlusal adjustments or your fabulous reconstruction
8. If untreated, you could lose all your teeth-facial asymmetry-spend fortune dentistry chasing occlusal ghost
9. OA management is hard work for patient, there is no fix it as they demand
10. Patient, dentist, and Orofacial pain specialist must team up for success
11. OA cannot be treated by dentist, dentist is professional responsible for teeth
12. The bone loss in TMD is a jaw joint-muscles-ligaments problem, thus it is orthopedics & medical

Muscles are over recruited from multiple sources overloading joint and pulling & tearing lateral ligament of TMD disc displacing disc in anterior medial direction until disc totally lost and condyle overloads retrodiscal tissue causing perforation in tissue, allowing bone on bone contact. Now, we lose bone until we lose height bone and loss joint space loading posterior tooth same side. The following are muscle recruiters:

1. Parafunction
2. Tension muscles
3. Chewing-Talking-swallowing
4. Tooth Bracing
5. Dual bites
6. Posturing
7. Chewing gum/habits
8. Protecting damage joint.
9. Malocclusion
10. Bracing due pain
11. Neck brace hyoid braces chewing muscles

Bite Changes cause by

1. Sudden loss disc
2. Bone loss condyle

Moderate-severe damage in TMD causes bite changes:

1. Completed displaced disc sudden loss causes condyle to elevate in fossa to load the posterior teeth on one side. it can be episodic stuck or stuck for time, during the loss of disc the condyle on that side elevates (loss of disc space) and loads the same side molars. Sudden, short duration, bite change
2. Bone loss in condylar head elevates the mandible in posterior to load the posterior teeth on one side. Can be enough for patient perceive by difficult chewing or feel bite changes. Can be significant enough for dentist to see posterior open bite on opposite side. Most time is gradual bone loss and gradual bite change, but it can be sudden.

Dual Bites: (please unhighlight these two dual bite & atypical toothache)

1. jaw joint bite does not equal tooth bite
2. 10 % have small difference
3. 5 % have moderate difference

Atypical Toothache: A toothache in healthy tooth can be caused by bone loss in condyle overloading the 2nd or 1st molar on same side.

It is the best interest of patient that we serve science not sales !

Diagnostic tree for atypical toothache: so if it is not inside nerve, the patient needs a diagnostic clearinghouse for the other 6 causes of toothache, some are medical and some dental.

1. Tooth.
2. Ligament-PDL
3. Muscle.
4. Joint.
5. Trigeminal Neuralgia.
6. Atypical Odontalgia
7. Misc

Surgery for severe damage TMD: TYPES:

1. Menicus Plication.
2. Arthroscentesis.
3. Joint Replacement

1. Meniscus Plication used in 90's w/ limited success, some developed OA & condylar erosion
2. Arthrocentesis is surgery today
   • lysis adhesions
   • injection Hyaluronic acid
   • flush joint inflammation
   • may repeat for progressive improvement opening
3. Joint replacement is surgery for trauma and OA joints that fail arthrocentesis & conservative tx
4. Rarely does even severe jaw joint damage need surgery
5. Conservative therapy under OFPS is highly successful if the patient is passionate about healing

Restricted Opening can occur in Osteoarthritis, Low prevalence due OA low statistics, can have mild to severe pain, can be associated w/ bite changes, temple HA, ear pain.

1. Sudden stuck-blocked-can’t open-restricted
2. Open wide-yawn with loud pop
3. Can’t open more 1 finger opening, episodes
4. Moderate-severe pain in jaw or ear
5. Presentation
   • may come & go,
   • may get stuck & stay stuck,
   • Restriction maybe 1-2 fingers
6. Main causes: Trauma-Tension muscles-Parafunction

Restricted opening is hint of moderate damage to TMD.

1. Complete displaced disc
2. Severe damage (OA) to TMD.

Restricted opening means Urgent referral by dentist, hygienist, PCP, rheumatologist, ENT, PT, Biofeedback, periodontist, endodontist, anesthesiologist, rheumatologist to orofacial pain specialist increase chance of healing and improve eating ability.

Bone loss in TMD:

1. Osteoarthritis.
2. Rheumatoid arthritis

If you have any patient diagnosed with OA, but is not wearing orthotic. Beware if a sudden bite change occurs, the bone loss in one TMD's may have been reactivated and needs referring back OROFACIAL PAIN SPECIALIST.

RHEUMATOID ARTHRITIS

TMD symptoms predominantly develop within 5 years of symptoms in major joints of body.

This makes early recognition of pain & inflammation in TMD important for enabling Rheumatologist to refer to Orofacial Pain Specialist for early treatment and prevention of irreversible damage in chewing system.

Most rheumatoid arthritis patients should be referred to orofacial pain specialist, especially if signs & symptoms of grinding/clenching-trauma jaw-anxiety-MVA damage in TMD.

Symptoms of synovial inflammation-cartilage & bone destruction is same for RH as OA

Any rheumatoid arthritis patient with any clenching & grinding should have a orthotic to prevent TMD damage