Your temporomandibular joint, or TMJ, is formed where your jawbone connects to the temporal bone of your skull. The joint works as a gliding hinge that allows for optimal range of motion. The bones of the TMJ are covered with cartilage and separated by a small disc that absorbs shock and promotes smooth movement.
The TMJ enables you to talk, chew, yawn, sing and open and close your mouth. Sometimes the TMJ becomes painful, and it may even freeze up, making it difficult to open and move your mouth. Disorders of the TMJ most often stem from overuse of the muscles surrounding the joint, or from postural issues that affect the alignment of the upper body, neck and jaw.
It is not difficult to recognize disorders of the TMJ, although jaw pain can have other origins, and can even be a symptom of heart attack. Common symptoms of TMJ dysfunction include:
In most cases, TMJ disorders arise from overuse, where the muscles that move the jaw become fatigued or tight from chewing or stress. However, poor posture or excessive use of electronic devices can create misalignments in the upper body that affect TMJ function.
A medical history and physical exam can help determine if your jaw pain stems from TMJ dysfunction. Your doctor may listen to your jaw as it moves and palpate the jaw area to pinpoint pain and tenderness.
At NYDNR, we use real-time diagnostic ultrasound, which enables us to view the TMJ in motion. Ultrasound gives us clear images of the TMJ and surrounding tissue, to help us identify the specific source of pain. Dr. Kalika, our clinical director, is a trained and certified expert in diagnostic ultrasonography.
Traditional treatment for TMJ pain may include muscle relaxants, pain relievers, injections or surgery. However, physical therapy can help correct the underlying causes of TMJ pain without the expense, side effects and discomfort of medical treatment.
TMJ pain often stems from tight muscles and connective tissues. Manual massage therapy can help stretch and relax tight jaw muscles, relieving pain and restoring function.
The most common source of pain in TMJ syndrome comes from within the TM joint capsule. Laxity and/or tightness of the capsular tissue can cause the disc to sublux, causing painful clicks. The capsule responds very well to manual intra-oral mobilization.
Postural issues in the upper spine and neck can cause your TMJ to become misaligned, leading to pain and dysfunction. Corrective physical therapy exercises and improved postural habits can save your spine and jaw from pain and dysfunction as you age.
Gentle chiropractic treatment can help restore TMJ alignment and reestablish vital brain-body neural connections.
Dry needling is another successful approach for eliminating trigger points in the masticatory (chewing ) muscles. Dr. Kalika uses Ultrasound Guidance for Dry Needling, to ensure precise targeting of trigger points.
TMJ doctor Kalika completed advanced coursework with Dr. Mariano Rocabado, one of the world’s leaders in this field. In addition to attending several courses, Dr.Kalika was invited by Dr. Rocabado to complete an advanced clinical internship in Santiago, Chile, where the two doctors teamed up to evaluate and treate numerous patients with a wide variety of temporo-mandibular pain, headaches, neck pain and whiplash.
Many recent studies support the observation that myofascial trigger points frequently contribute to migraines and tension-type headaches, as well as pain in the jaw, cheeks, and teeth.
Dr.Kalika is a pioneer in the field of Ultrasound Guided Dry Needling, which he believes yields superior results in the treatment of oro-facial pain and headaches. Our expertise in treating oro-facial pain is recognized by many NYC dentists, maxillo-facial surgeons and neuromuscular dentists.
Our TMJ physical therapy approach is very integrative. We use elements of Cranio-Sacral therapy, Cranial Osteopathy and Rocabado’s approach to eliminate pain and dysfunction in Temporo-Mandibular joint, neck and cranium. Much attention is paid to posture, hypermobility, visual axis, movement patterns, and perpetuating factors.
Following the initial physical therapy examination, Dr. Kalika develops a comprehensive treatment plan, which forms the basis of the physical therapy program. We work closely with referring physicians, dentists, oral surgeons, ear-nose-and-throat specialists, and orthodontists.
Patients with Temporo-Mandibular joints (TMJ) pain often become victims of excessive fragmentation of our complex healthcare system. An individual with persisting pain in the TMJ area may very soon find himself on a long, if un-amusing, journey through the complicated maze of the medical profession. From a dentist office to a neurologist and chiropractor, through physical therapist, to an otolaryngologist he would go. Even psychiatric advice is often sought when everything else fails. Each specialist would undoubtedly have the insight on the heart of the matter subjecting the patient to various tests and devising a treatment using methods specific to his area of medicine. Much too often however such a patient would emerge from his quest with his insurance coverage strained and his TMJ pain fully intact.
Most of the time a patient with TMJ problem initially will be seen by an orthodontist or a neuromuscular dentist, because in theory TMJ pain falls within the scope of their expertise. The truth however is that even though TMJs are anatomically located inside the oral cavity their dysfunction and pathology is rarely, if ever, caused purely by strictly dental problems, such as malocclusion or poor dentition. The simplest proof to this is in the fact that elderly people who, for obvious reasons, have much greater incidence of malocclusion statistically suffer much less problems with their TMJs. Another study involving postmortem examination found that a large number of deceased individuals in whom severe malocclusions were detected had no documented history of TMJ problems.
Due to the deficiencies in healthcare classification standards and overabundance of conflicting scientific evidence about the origin of symptoms like pain in the facial area and TMJ region, persistent headaches, earaches, ringing in the ears, decreased hearing, limited mouth opening, popping or locking of the jaw, hypertonicity of the masticatory musculature and other similar complaints they all are regarded as related to an assortment of conditions involving the Temporo-Mandibular apparatus. The collective term Temporo-Mandibular Disorder or TMD has been coined to describe these conditions without pointing out their etiologies. However, doctors and patients still refer to these symptoms as TMJ pain syndrome.
TMD is a set of related pathological changes, which produce musculoskeletal symptoms in the jaw. The term TMD is deliberately broad and is only used to organize a variety of dysfunctions and disorders that result in abnormal function of the muscles and joints of the jaws.
In order to understand TMD and Orofacial pain the clear definition of Temporo-Mandibular complex must be laid out. Temporo-Mandibular complex is an indelible part of the locomotor system responsible for such vital functions like chewing, swallowing, speaking and breathing. It includes mandible (lower jaw) bilaterally articulated with the maxilla (upper jaw) by highly versatile Temporo-Mandibular joints (TMJs). The skeletal infrastructure is powered by masticators (chewing muscles), which depress, elevate, protrude and retract the lower jaw. The lower jaw is the main movable component of the Temporo-Mandibular system. Supra- and infra- hyoid muscles, which assist the hyoid bone in its various movements, are closely connected with the above-described functionality. Last, but not least, another important element of Temporo-Mandibular system is the cervical segment of the spine, which is intimately linked to the functioning of the orofacial system. Of utmost importance is the fact that Temporo-Mandibular complex represents an integral part of the whole Locomotor system, meaning that TMJ movement is controlled by the same neurological mechanisms that control any movement in the body.
Temporo-Mandibular system is densely innervated and its motor control is provided through the integration of stimuli projected from various receptors within the oral cavity, cervical proprioceptors, and receptors located in the nasopharyngeal and gastro-esophageal areas. Sensory input coming from visual, auditory and vestibular areas also affect the function of Temporo-Mandibular system. Not least important is the association of the respiratory system with Temporo-Mandibular functionality. Integration of all of these stimuli with the input coming from muscles and joints of entire Locomotor system, provide the neurological basis for motor control of the Temporo-Mandibular complex.
Temporo-Mandibular system is one of the most active and powerful structures of human body. It works during the day and while we are asleep. Due to the massive continuous workload and considerable forces exerted by its components it is a subject to breakdowns. Fortunately for the patient the Temporo-Mandibular system is very resilient and capable of self-repair when a proper treatment is administered.
Causes of Orofacial pain arising from within the Temporo-Mandibular system:
Diagnosed TMDs fall into three basic etiological categories:
The first category belongs to pure myofascial etiology resulting strictly from hypertonicity of muscle of mastication and muscles of the cervical spine.
The second category is a mixed etiology. Hypertonicity of masticatory muscles in conjunction with some degree of intra-articular TMJ dysfunction (hypo- or hypermobility in one or both joints, with or without periarticular adhesions).
Resulting from true intra-articular pathology with locking of the jaw.
It must be mentioned that mixed etiology includes various contributing factors listed above.
TMDs of any etiology in general seldom require a surgical intervention. Historical research data has shown that jaw repositioning (one of the common measures taken in combating TMDs in adults) has failed to yield any significant improvement in the recovery ratio. It is a risky and expensive procedure that seems to have been developed by creative dental specialists out of desperation due to the lack of better, scientifically proven alternatives. Such dental measures like occlusal grinding, expensive crowns and bridges, and full mouth restorative procedures also lack sufficient statistical evidence proving them to be effective as cure of TMDs. However, TMJ custom made appliances based on radiographic positioning in combination with specific TMJ physical therapy or chiropractic has proven to be the most effective measures in treatment of TMJ pain disorders.
Conditions from Categories 1 and 2 (see above) fall into the field of neuromuscular therapy , such as chiropractic or physical therapy specializing in TMJ treatment. Special attention has to be devoted to dysfunction in the Locomotor system as a whole because the local manual approach alone may not be sufficient. Treatment of the entire Locomotor system is necessary to avoid recovery delay and subsequent chronicity. This is especially the reason why intraoral appliances, such as dental splints, should only be used in conjunction with neuromuscular physiotherapy or as a supplemental home therapy to consolidate the recovery achieved by the neuromuscular treatment. Over the counter splints can be tried at first before committing to more expensive custom made appliances.
TMDs caused by intra-articular pathology (category 3) require close cooperation between orthodontist or maxillofacial surgeon and neuromuscular specialist. The world’s scientific authority recommends treating these cases conservatively until maximum improvement is achieved before committing to surgery. At present about fifty percent of such cases are managed without any orthodontic or orthoghnathic surgical intervention. At this stage custom made appliances is a must. Only when long rehabilitative approach with specific TMJ physical therapy has failed surgical intervention may be considered. It must be up to the neuromuscular specialist to make a sound judgment, based on good clinical skills and clear understanding of structural pathology of the TMJ, whether the conservative care is no longer effective and refer the patient for surgical consultation.
Although, most of TMJ pain disorders are self-limiting, they could generate excruciating pain and cause significant distress to the patient. Improper TMJ treatment can lead to chronicity, emotional distress and create a devastating impact on the patients’ quality of life. When chronic TMJ pain is present pain medication and neuromuscular therapy may not be sufficient. Meditation, relaxation and referral to a psychosocial specialist or a pain clinic may be warranted.
At DNR’s office located in Manhattan, Midtown we use comprehensive TMJ treatment approach consisted from specialized TMJ physical therapy exercises such as Roccabado and others well-accepted protocols. Manual intraoral TMJ therapy we use in our NYC facility is combined with cranial osteopathy. TMJ function is intimately related to function of the cervical spine and shoulder girdle. We use DNS ( dynamic neuromuscular stabilization ) approach to restore functional connections between masticatory muscles and cervicocranial and scapulomandibular muscles. We use soft tissue mobilization techniques to address deep cervical fascia and its interconnection with craniomamdibular system. For myofascial trigger points in temporo mandibular and cervical muscles we use low energy ESWT devise and cold laser, which are quite hard to find even in New York.
TMJ pain can become chronic and resistant to treatment if professionals who specialize in TMJ therapy do not timely address it.
and a faulty diagnosis can make treatment a total waste of time.
Failure to accurately diagnose a condition in its early stages can lead
to chronic problems and sometimes devastating results.
Diagnostic musculoskeletal sonography (MSUS) provides the perfect tool for the rehab practitioner. Yet many doctors and physical therapists have no experience with MSUS, are unaware of its advantages, and have no idea how to use it as a diagnostic tool.
Below is a prime example of how ultrasound can take the guesswork out of diagnosis.Successful Treatment
A bad physical therapy experience is one of the primary causes of unnecessary surgery.
We have equipped our clinic with the latest research-grade technology to arrive at objective and accurate diagnoses, and to objectively measure our patients’ progress.
Most importantly, we are the only facility in the US where structural medical diagnosis is reflected in functional treatment, and vice versa.
In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.
Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.
The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.
Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup
Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)
Complete tear of rectus femoris
with large hematoma (blood)
Separation of muscle ends due to tear elicited
on dynamic sonography examination
