Diagnosis

Again this is complex and many pain causes and syndromes are too complex to deal with in a single manner. At TMJ & Sleep Therapy we look at the overall pattern and see how it impacts on a patient. If there are all the obvious causes but little impact then our treatment will be little or nothing. Conversely the reverse is true. If the cause has a great impact on you we will focus our attention on the origin and then the cause.

This is diagnosis. Starting with a comprehensive screening program a questionnaire is filled and gone over. Then we move onto the consultation where a number of screening questions are made. These are designed to rule out some causes and to confirm others. From here the doctor will make a physical examination and some neurological tests. The physical examination is designed to look at the whole body and its asymmetries. This starts at the feet and ankles working through to the shoulders and the head. The face too is noted to ensure that eyebrows are level, ears and the top jaw should all be parallel to the horizon. This postural analysis will reveal where asymmetries have their origin.

This is backed up with a series of head/neck x-rays taken from the front and the side. Other x-rays are taken of the jaw joint, a highly innervated area and the most common single source of head pain.

We use electronic means to listen to and measure the vibrations generated inside the jaw joint and the electrical activity of the chewing muscles.

Plaster casts are taken, a record of your bite and of the relation of the top jaw to the rest of the skull is made and these are taken to a special ‘articulator’ that shows these asymmetries.

The full diagnostic examination is as follows.

Screening pain and sleep questionnaire.
Screening consultation.
Muscle trigger-point examination.
Postural evaluation.
Autonomic nervous system evaluation.
Face, head and oral examination.
A series of postural photos
A series of x-rays (Lateral Head , Frontal Head, Jaw joint and Panorex)
Jaw joint vibration recording and analysis.
Jaw muscle testing.
Jaw motion testing
Plaster casts mounted and analysed

Consultation of the results of this diagnosis including a treatment regime and recommendations.

The Screening Questionnaire: This uses the Epworth scale. Asking a series of questions relating to sleep and how it affects you and the types and scale of pain we can gauge the impact that the pain has as well as what its likely cause and origins are.
The Clinical part of the examination begins with a series of quite specific questions about the frequency, severity and other quantitative and qualitative aspects of the symptoms. It will also review the first questionnaire. Muscle trigger points and body symmetry are looked at and assessed.

X-rays: There are three or four normally taken depending upon the need and these are digitised and read. These look again at symmetry and the size and shape of the airway. Airway is critical as a compromised airway will force the body to hold the head off-centre to maximise the airway. This causes muscle pain and bone degradation.

Postural analysis: This reveals asymmetries in the feet, ankles, legs pelvis and torso. Such asymmetries are compensated for by the muscles pulling on the opposite side and this creates pain in those muscles and then the adjacent muscles that are called upon to support and assist. Also these twists in the torso and below are reflected in the neck. The neck is the anchor for all the jaw opening and ‘steering’ muscles. So a change in the feet, legs and pelvis will influence the jaw muscles.

Autonomic Nervous System: This is the Parasympathetic system. Generally it remains balanced with the adrenaline tending to increase heartbeat (fight and flight) being balanced by the opposite which calms things down, improves breathing and digestion. When these are not in balance, you are either hyper-active, stressed and unable to calm down, but always tired as all your resources have been used up.

If the Noradrenaline is dominant, you are sluggish and half asleep a lot of the time. We have simple non-invasive tests to measure the activity of each system.

Photographs: To measure the body we use photos and an overlay grid. This allows a record and a baseline to be made and any treatment can be compared. The photos include the whole body from front back and sides. Top third, again from the front and side. The lower legs from front and back. There is a series inside the mouth too.

JVA Joint Vibration Analysis: is a method of ‘listening to the noises’ inside the jaw joint. This will give a very specific amount of information about the time in the open/close cycle, the volume of noise and the quality. Each factor gives critical information about the pathology going on.

Jaw Tracker. By gluing a magnet onto the lower teeth and then using a detector to monitor the movement it is possible to see what pathway including all the ‘bumps’ the jaw takes. This happens so fast we need to be able to record it and slow it all down and watch it on a computer. Jaw tracker allows us to see the jaw’s motion in real time and assess its abnormalities. These too reflect the state of the joint and the tone and action of the jaw muscles.

Plaster Casts: These are the commonly taken casts but with certain aspects focussed upon. There are a number of important anatomical points that we look for. Then we ‘mount’ these casts in a special jig called and articulator and these casts are aligned with a face-bow. This allows us to see and to measure the amount of twist in the jaws and the skull. Both these aspects are critical both in orthodontics and in Cranio-facial pain. By using a Face-bow which fits in the ears and carries a wax-covered bar, you bite can be recorded and this will show the relation of ears (skull) to top jaw. Stresses and strains in the skull make the treatments unstable unless they are addressed. The origins of these must also be discovered and resolved where possible. Asymmetric bases for the muscles will result in muscle over-activity or ‘hyper-activity’ and pain.

Bite registration: when you bite the place you bite is determined by the teeth, be they your own teeth or a denture. However it is very common for this place to be different to that determined by the joint acting as a hinge. The ideal is to have relaxed and symmetrical muscles, anchored to symmetrical bones. The bite registration needed to assess your current state may be taken in a number of ways including Tensing. This is using tiny electrical charges to ‘de-programme’ the muscles or remove any memory they may have of their incorrect bite. This is often recorded in warm wax or something similar. We also take Phonetic bites that are determined by speech patterns. When you say certain sounds it is only the muscles working and this can give an accurate bite.

When all this information is gathered, it is appraised and a diagnosis arrived at and a method of treating your specific issues can be arrived at.

Treatment methods

When your bite is wrong

If the bite is wrong it relates to both the teeth and their position in the jaw bone such as buck-teeth or crowding, but also the jaws themselves are not parallel to the rest of the skull. Often we note that eyes are not level nor are ears and these problems are caused by postural compensation and that is usually the result of something outside the jaws. Blocked nose is a common example. This will force you to breathe through your mouth. The best position for this is when you hold your head down and forward. Such a position will alter your balance and immediately your posture changes.
Similarly there are feet, instep, leg and pelvic issues. One short leg will alter the whole posture. This will be reflected in the face.

That is why we look at feet. If there is an issue here we get the help of a podiatrist. Similarly there may be pelvic and back issues and here we use either a chiropractor or osteopath. We chose carefully as not all are well trained in this. Cranial osteopathy is quite powerful.

Addressing these issues we will delegate the problems to those best able to help.

Now we can deal with the problems of the bite and the jaw position as well as the jaw joint.

Where the jaw joint is damaged or compressed, we have to reposition it into a more favourable place. It is essentially a ball and socket joint, but complicated as it is designed to move sideways and forward to the point that it is designed to ‘dislocate’. However it relies on the muscles to move and for a pad of cartilage to keep the bones apart.

If the bite position including the overall height is too short or low the ball will be forced deep into the socket. This will crush the cartilage disc and maybe push it right out of the socket. This expulsion is the ‘click’ or ‘pop’ heard when chewing or opening the jaw. Where the teeth force the ball back against the back wall of the socket, the delicate tissues that anchor the disc, that provide blood and nourishment as well as the very sensitive nerves are all squashed. This both damages them and stimulates the nerves to send pain-like signals to the brain.

The solution is to find the best position for the jaw joint and using a temporary plastic splint (orthotic) see how the jaw and the rest of the body approves. Where there is a favourable response I will make these changes permanent. These permanent changes are made with orthodontics or by placing crowns. Because these changes can be irreversible, as well as expensive we use the orthotics to test the prudence of such a move before committing to anything that we can’t easily change.

So to put the jaw in a better position is done first with a combination of orthotic therapy and co-treatment and later with orthodontics or crown and bridge. Many times these may be what you were seeking and the TMD or CFP were not linked. Many patients are surprised to find there is a relationship between the jaw position, crowded teeth and headaches.

The finer details of any treatment would be part of the record taking, diagnosis and consultation well before anything was undertaken.
Please note that while this may sound like many of these aches and pains sound like you, this is never intended as a specific ‘diagnosis’. While there may be common problems with many patients, everyone is individual and the treatment must reflect that.