THE VICIOUS CYCLE OF TEMPORO-MANDIBULAR-JOINT DYSFUNCTION

The Vicious Cycle of TMJD, 

And How It Affects Its Treatment 

Temporomandibular Joint Dysfunction (TMJD) arises when the harmony of teeth, facial muscles, and the temporomandibular joints no longer exist. Some of the clinical symptoms are:

• Headaches
• Neck and shoulder aches
• Ringing in the ears and ear congestion
• Clenching/grinding
• Limited opening/movement of the lower jaw
• Dizziness/vertigo
• Clicking/popping of the jaw joints

Patients suffering from these symptoms have learned to accommodate and to live with the daily pain. They have become "the chronic wanderers" going from one medical doctor to the other in the hopes to find an end to their daily misery. Regrettably when competent clinicians cannot find an organic basis for these symptoms, they often suggest it might be psychogenic and/or readily choose the pharmacological route to appease their patients. As these patients are told and retold that there seems to be no tangible basis for their pain, their anxiety, anguish and uncertainty mounts sometimes to levels where depression sets in and they turn to drugs and alcohol to alleviate their feeling of despondency and their symptoms. This in turn can lead to disruptions in work place, relationships and personal achievements. In extreme cases and rare occasions even contemplation of suicide.

The Vicious Cycle

TMJD is a chronic degenerative disease which often takes years to develop. There are many contributing factors that if not diagnosed can and will affect the outcome of its treatment. Every person/patient has a unique personality and biological make-up, and it must be considered when discussing cause and treatment of TMJD. 

The three factors affecting treatment and consequently the outcome are:

1. Structural
2. Emotional
3. Biochemical

A person suffering from TMJD is affected by these three factors in some shape and form and seldom to an equal extent. Hence, it is fundamental when diagnosing TMJD, to asses the relative impact of each of these factors. Many patients may remain oblivious of any symptoms until one day they wake up with, for example an excruciating headache. It is like filling a cup of water to the rim and one keeps adding droplets until all of the sudden there is a spill over. Similarly, many different lifestyles can combine which could aggravate TMJD - such as structural imbalance, stress, depression, fatigue, nutrition and even simply routine check up visits to the dentist. Any of these are like "the single drop" in the cup of water. 

Structural

One of the primary root component that is always present in TMJD is structural imbalance. Structural Imbalance. We often hear this phrase used along with the diagnosis of our aches and pains. But what does it mean? The best way to explain it is to start from the opposite end, "Structural Balance". 

Structural Balance refers to the optimal positioning of our bones and joints. This means when weight or pressure is applied to a part of the body, it is effectively passed through the structures, e.g. bones, joints and muscles. These structures are designed to hold weight well in a particular direction and not so great in other directions. Structural imbalance is simply when bones, joints and muscles are not in their optimal position when weight and pressure is applied. 

  

The structural imbalance in the jaw is also known as "mal-occlusion" or simply a "bad bite". This means that the upper and lower teeth do not close together in the right way. Just as a chair needs four legs in order for one to sit on without falling over, similarly all teeth need to fit firmly together to support the muscles in the face and the muscles used for chewing and swallowing. Teeth are an extension of the skeletal system. The lower jaw is related to the skull via the Temporomandibular Joints (TMJ) and held in place by a collection of muscles. Both the position of the TMJoints and the muscles are determined by the way the upper teeth and lower teeth fir together. When teeth are together they are in occlusion. The occlusion dictates the relation of the jaw to the skull which is also know as the cranio-mandibular relationship.
In the presence of mal-occlusion the skeletal system is in disharmony with neuromuscular system. This means that the teeth/occlusion is forcing the TMJoint's and muscles into a strained position. The aforementioned state increases the natural demand to the muscle and nervous system beyond their natural biological capacity and places them in a spasm cycle.
It is just like walking with a pebble inside your shoe. After a few yards the pain becomes annoying and will twist and torque your hip into all kind of different positions to avoid walking on the pebble inside your shoe (this manipulation is known as accommodation/avoidance). After few more painful steps the pebble will start to feel like a large stone and your foot, leg and body is left in tremendous agony and distress. The former metaphor can be related to what happens to the muscles of the face and jaw (oro-facial muscles) when they are forced into an unnatural position by virtue of a "bad bite". Eventually the muscles become strained and painful. This strain on the muscles causes an alteration in their shape and tonus. To compensate for this the other muscles such as the neck, shoulder and back have to accommodate for this unnatural position, which in turn places them into a strain and spasm.

"Muscles under constant strain are in pain"

Emotional

Many medical/dental professionals are still of the opinion that TMJD is a psyhosomatic (psych=mind, soma=body) illness, starting in the mind and manifesting itself in the body. Sometimes humans continually complain of a discomfort or a pain for which a health professional cannot find an organic cause. The pain or the discomfort, however, is very real to the affected person. Physical complaints with no apparent medical basis may be a reflection of a stress in social settings, relationships, work environment and or other stressful situations for example. Stress, as it affects the body and the mind, has an effect on some illnesses, such high blood pressure, ulcers, and can influence as how humans perceive the symptoms of the illness, how he or she deals with the illness, and the rate and success of recovery.

It is believed, however, that for most part TMJD has its origin from a structural imbalance or "somatopsychic". The resulting pain in the muscles (soma) causes a feeling of anxiety, tension and stress (psyche). There have been numerous studies on how the impact of being sick affects us mentally and emotionally. For instance emotional reactions when having a daily headache could include:

• Inability to perform up to ones personal and public expectations
• Anxiety
• Depression
• Frustration
• Lack of energy
• Anger and hyper-irritability
• Fear of the unknown

Thus, it is apparent how coping with a chronically painful condition such as TMJD can place someone under tremendous amount of emotional stress. Mind and body is a complex interconnected highway, so that even though the problem may stem from a structural imbalance in the jaw, the resulting discomfort will affect the mind as well.

"My silence is just another word for My pain"

Biochemical

 

The human body and mind has certain arsenal to its possession when in pain and in stress. In pursuance of pain and stress it prepares itself for either "fight or flight". These are short term positive coping mechanism in the presence of stress. Unfortunately when in pain, under stress and emotional constraints at the same time, we tend to add to the problems by adopting less favorable habits such as:

• Over-eating
• Drug and alcohol consumption
• Medications - prescribed and non prescribed
• Sleeplessness
• Not exercising

Soon the body adapts itself to long term chronic stress. In this second stage, the body's defense hormones operate in an above-normal rate. In addition to the aforementioned ill-habits, just like your car would eventually run out of fuel, the body will soon be depleted from its natural fuel supply. At the third stage, exhaustion sets in and the body breaks down. This stage makes it very difficult to treat a chronic disease such as TMJD. The astute clinician treating TMJD may be successful in properly aligning the structural imbalances but some deep seated emotional and bio-chemical disorders need to be managed by appropriate experts or the treatment will fail.

With TMJD the body is placed in constant stress. The extent and severity differs from individual to individual. Some people may have an occasional click in their TMJoints and some some may suffer from constant, severe, daily pain. In either case, the body prepares itself to fight against the stressor. Biochemical changes occur to provide the body with energy to compensate and adapt. This energy is limited however, and eventually will be depleted at a faster rate, especially in the presence of ill-habits and some emotional conditions. This in turn will affect the success of treatment and its longevity. It is of utmost importance that the treating clinician has the ability to recognize the biochemical and emotional factors of their patient and through discovery and co-communication plan for a successful treatment.

"It is important to know the person who has the disease as to know the disease the person has."