Jaw Muscle or TMJ Pain? Will a Dental Splint Help?

Is my jaw pain coming from my TMJs or my muscles of chewing?

Many people suffer pain around the jaws and muscles and think they have “TMJ”. We all have TMJs, as it is just the name of the joint that occurs between the lower jaw (mandible) and the skull.

This lay term “TMJ” refers to a common condition of pain in and around the jaws that afflicts quite a high percentage of the population at some point in their lives.

The most common symptom is TMJ clicking, and around 30% of the adult/teen population experience this. In most cases, just an awareness and monitoring of this is all that is needed from the dentist.

TMJ clicking, along with/or with chewing muscle, neck and shoulder pain, does need careful assessment and management.

Why thorough assessment must come first

The correct treatment cannot be determined without a thorough assessment of the signs, symptoms, and history of the problem.

Some people rush off to either get BOTOX or to a dentist inexperienced in this type of problem to get a splint made. This is NOT the right way to address these issues, and thorough assessment first is needed.

The problems are most commonly coming from the masticatory muscles (chewing muscles), or from within the TMJ(s), and the two need to be distinguished, because there is no single treatment that fits all cases.

Muscle pain (MPD) vs joint pain (TMD)

The muscles involved in chewing and head support (neck and shoulder muscles) act in unison, and people who grind or clench their teeth subconsciously often suffer from Myofascial Pain Dysfunction (MPD) or Myofascial Pain with Referral.

If the TMJ is the main source of pain, an entirely different treatment protocol is required, and BOTOX is not going to achieve much.

Each of the two types of problem requires a different type of splint. The typical splint correctly prescribed and fitted for a TMD is likely to worsen symptoms in a patient with MPD, and most dentists who make splints make the one type for all. This is a flawed philosophy based on the lack of training in the dental university undergraduate training and relatively few good ongoing training courses as postgraduate study.

What is the typical flowchart in managing these issues?

1. Thorough initial consultation

A long consultation by a dentist with a lot of experience in this type of problem. Several general X-Rays are likely to be prescribed. Depending on the nature of the problem, sometimes a TMJ MRI is suggested, and this is quite a costly service but the only way of knowing what is happening with the cartilaginous disc inside the TMJ.

2. Physiotherapy

Depending on the results from the long consultation and the X-Rays, the usual next stage is seeing the correct physiotherapist and at times a myofunctional therapist.

3. The appropriate splint or dental orthotic

If after the initial management by the Physiotherapist there are still symptoms, the usual next line of treatment is construction of the appropriate type of splint or dental orthotic.

• For a MPD case, this is often an anterior positioner splint, which reduces the strength of clenching from the masseter, temporalis, and medial pterygoid muscles.
• For a TMD case, this is more commonly a flat-plane (Michigan) splint.
• Certain TMJ pathologies require an indexed Gelb splint.
• For any patient with obstructive sleep apnoea, a Mandibular Advancement Splint is often required.

It is necessary to ensure the correct type of splint is recommended. Some types of splints can only be used for a short period of time, typically 3 to 6 months, and for some problems, a day-time wear splint may be indicated.

4. BOTOX — a role, but never the first line

BOTOX is often requested by patients, and it does have potentially a strong role in management, but it should NEVER be considered the first line of treatment in TMD/MPD cases. It is both expensive and only lasts typically 3 to 4 months before it is needed again.

Incorrect use by various practitioners looking for aesthetic benefits for their patients to control facial/neck skin wrinkles is often administered inappropriately to manage myofascial pain, and we frequently see inappropriate dosing, incorrect placement, and the administration of one muscle causing surrounding muscles to overcompensate for the reduction in function of one muscle. This is not the role of a nurse injector or Dr who does cosmetic BOTOX, to treat MPD, as they are usually not trained in these techniques.

5. Arthrocentesis

In various cases of internal derangement in the TMJs, a procedure called Arthrocentesis is prescribed, and this is typically only done on referral to an Oral and Maxillofacial Surgeon.

6. Surgery — a last resort

Rarely is any type of surgery to the TMJ required, but various procedures to reposition the cartilaginous disc may be indicated, and the absolute last resort in highly symptomatic TMJ cases is actual TMJ joint replacement.

7. Chronic pain and psychosocial support

Patients who have suffered either TMD or MPD for over 6 months invariably have a psychosocial component that requires an additional form of support and treatment, and often a clinical psychologist is required to help with cognitive behavioural therapy or hypnosis to manage living with chronic pain.

Often contacting your GP Doctor is worthwhile to ask to have a Medicare Mental Health Plan for subsidised Psychologist sessions.

A final word

Patience is needed in managing these conditions, along with a very detailed assessment. Regrettably, most dentists do not have the training to manage complex orofacial pain cases.