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"Do you ever have any popping, clicking, or pain in your jaw joint?" Hummm.
If that sounds like your version of a TMJ exam, you're missing the big picture. One of my favorite sayings is, "The mouth is attached to the body." In the realm of the TMJ, we could modify it to say the entire body is interconnected.
A good case could be argued that the TMJ exam could commence at the point of the appointment where the patient/client is escorted back to the treatment room. The gait and, more importantly, the posture play a critical role in finding problems that could manifest themselves as TMD.
As a person stands erect, they should be rather square. That is, the head should be perpendicular to the floor; the shoulders and hips should be parallel to it. The side view should reveal the person's ear, shoulder, and hip in a straight line perpendicular to the floor (in aword, plumb). The head forward posture is very detrimental to all the muscle groups of the upper body as well as the TMJ.
Even flat feet can come into play. No kidding! Hanna Franke, a certified neuromuscular therapist who has been educated in the St. John's technique, helps me explain it. Let me take you on a little journey to illustrate this situation. First, a mention of the body's righting system.
The body insists that eyes be horizontal. It will do whatever it needs to in order to accomplish that. It is a primary goal of the brain to have the eyes even. Back to the feet. Let's say the arch on one foot has fallen, this rotates the lower leg to bring the knee mesially and, in turn, the hip. The hips may even become rotated, but let's not worry about the 3D version. We'll try to work with two planes. Suffice it to say that a rotation will complicate matters in a negative way.
The hip above the foot with the fallen arch is lower than the other, because the leg is now a little shorter. So now we see a person tipped to the side of the fallen arch, the eyes are no longer horizontal, a torque of the waist creates a curve to establish the perpendicular relationship between the shoulders and the floor. The "S" curve, that we know as normal from the side view, is now abnormal from the front view. We have the dreaded double S, the curve on two planes when only one is normal.
Now the shoulder on the side with the flat foot is higher than the other in order to compensate, and the eyes are still askew from their required relationship with the horizon.
Sooooo, the head tips towards the high shoulder, pulling the trapezius, which is of course attached to the head which pulls on the temporal muscles with affect the TMJ. See my lovely artwork below.
Sometimes a person will come into your treatment room walking like this poor stick figure man and not even know he's in pain. Further probing is essential if this patient is to experience relief from the symptoms he is unaware of. This kind of skeletal arrangement is out of our purview, obviously. It is important, though, to have an understanding that we have a whole person here. A presentation of the person on the right should be questioned in depth about the probable symptoms.
Tingling is a big one. With this skeletal mal-alignment, for what ever reason, nerve impingement is highly likely. A question or two about tingling in any extremity or within the head and neck will likely bring a positive response. Frequency, duration, and level of headaches, muscle twitching, ringing in the ears, and visual disturbances are all likely symptoms. The patient may not put these together as caused by a single issue, but we can.
Now we have a partially educated patient in our chair. Because the TMJ is not a recognized dental specialty and we aren't specialists in this single joint, what are we to do? The first line of defense is usually the night splint/bite guard or some other gadget designed to keep the teeth apart.
The pain is most typically caused by a muscle spasm, any of the symptoms above is caused by a very small muscle spasm. The doctors at the TMJ Center in Middleton, Wis., argue winningly that, while the intention is laudable, a bite guard will give only temporary relief. Without knowing exactly which muscle is in spasm, where on the muscle this knot is, and how that muscle relates to other muscles and bones in the head, neck, back and the rest of the body, you're shooting in the dark.
Hard or soft appliances without proper diagnostics and collaboration with other specialists are just Band-Aid fixes. Invasive surgery is not always the answer. What other profession operates on a muscle spasm? We need more information! We (general practitioners as well as the specialists who deal with the most unique joint in the body) need an interdisciplinary approach. Dentists and hygienists in general practice need to know who to safely refer patients to. If we go through all the trouble of noticing a crooked man, eliciting a story of unknown pain, and raising expectations of relief, we don't want to send him to someone who blindly puts a piece of plastic between his teeth.
Dentistry is a small percent artfulness; the greater percent must remain science. Today's gadgets can spot a muscle knot a mile away. They can trace the path of the condyle. And tomagraphs give incredible views into the joint that makes a pano laughable.
Drs. Ballweg and Insolera are general practitioners who have a passion for treating disorders of the TMJ. They have studied the whole ball of wax for years and have a joint practice where they do diagnostic workups of moderate to severe cases. A Panelipse is not a great diagnostic tool, especially of the TMJ. The doctors take tomagraphs of the jaw in action, opening and closing, protruding and returning. They also hook up patients to a fancy machine (neuromuscular scanner/sonograph/ electromyograph) that graphs out the movement of the jaw. Looking at the printout makes it very clear where the problem is. The point is that there is more to a TMJ exam than "open" and "close." Posture is a key element that's available to us to help make a determination of potential problems. When we seat a patient, when we take radiographs, when we sit in the twelve o'clock position behind the head of our supine patient/client we can look for proper 90 degree angles. We can look for trapezoids instead of squares and ask probing questions. Find a dentist around your town who has a good handle on posture's relationship to the muscles of the head and ask them to speak to your office or hygiene component. Other great resources are those trained in the St. Johns method of neuromuscular therapy, physical therapists, or a well informed chiropractors. Collaboration between professionals is imperative if we want to treat the whole person.
Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].
