Temporomandibular Disorders (TMD)
Temporomandibular disorders (TMD) occur as a result of
problems with the jaw, jaw joint and surrounding facial
muscles that control chewing and moving the jaw.
What Is the Temporomandibular Joint?
The temporomandibular joint is the hinge joint that connects
the lower jaw (mandible) to the temporal bone of the skull,
which is immediately in front of the ear on each side of
your head. The joints are flexible, allowing the jaw to move
smoothly up and down and side to side and enabling you to
talk, chew, and yawn. Muscles attached to and surrounding
the jaw joint control the position and movement of the jaw.
What Causes TMD?
The cause of TMD is not clear, but dentists believe that
symptoms arise from problems with the muscles of the jaw or
with the parts of the joint itself.
Injury to the jaw, temporomandibular joint, or muscles of
the head and neck – such as from a heavy blow or whiplash –
can cause TMD. Other possible causes include:
Grinding or clenching the teeth, which puts a lot of
pressure on the TMJ
Dislocation of the soft cushion or disc between the ball
Presence of osteoarthritis or rheumatoid arthritis in
Stress, which can cause a person to tighten facial and
jaw muscles or clench the teeth
What Are the Symptoms of TMD?
People with TMD can experience severe pain and discomfort
that can be temporary or last for many years. More women
than men experience TMD and TMD is seen most commonly in
people between the ages of 20 and 40.
Common symptoms of TMD include:
Pain or tenderness in the face, jaw joint area, neck and
shoulders, and in or around the ear when you chew, speak
or open your mouth wide
Limited ability to open the mouth very wide
Jaws that get "stuck" or "lock" in the open- or
Clicking, popping, or grating sounds in the jaw joint
when opening or closing the mouth (which may or may not
be accompanied by pain)
A tired feeling in the face
Difficulty chewing or a sudden uncomfortable bite – as
if the upper and lower teeth are not fitting together
Swelling on the side of the face
Other common symptoms include toothaches, headaches,
neckaches, dizziness, earaches, hearing problems, upper
shoulder pain, and ringing in the ears (tinnitis).
How Is TMD Diagnosed?
Because many other conditions can cause similar symptoms –
toothache, sinus problems, arthritis, or
disease – your dentist will conduct a careful
patient history and clinical examination to determine the
cause of your symptoms.
He or she will examine your temporomandibular joints for
pain or tenderness; listen for clicking, popping or grating
sounds during jaw movement; look for limited motion or
locking of the jaw while opening or closing the mouth; and
examine bite and facial muscle function. Sometimes panoramic
X-rays will be taken. These full face X-rays allow your
dentist to view the entire jaws, TMJ, and teeth to make sure
other problems aren't causing the symptoms. Sometimes other
imaging tests, such as magnetic resonance imaging (MRI) or a
computer tomography (CT), are needed. The MRI views the soft
tissue such as the TMJ disc to see if it is in the proper
position as the jaw moves. A CT scan helps view the bony
detail of the joint.
Your dentist may decide to send you to an oral surgeon (also
called an oral and maxillofacial surgeon) for further care
and treatment. This oral healthcare professional specializes
in surgical procedures in and about the entire face, mouth
and jaw area.
What Treatments Are Available for TMD?
Treatments range from simple self-care practices and
conservative treatments to injections and surgery. Most
experts agree that treatment should begin with conservative,
nonsurgical therapies first, with surgery left as the last
resort. Many of the treatments listed below often work best
when used in combination.
Apply moist heat or cold packs. Apply an ice pack
to the side of your face and temple area for about 10
minutes. Do a few simple stretching exercises for your
jaw (as instructed by your dentist or physical
therapist). After exercising, apply a warm towel or
washcloth to the side of your face for about 5 minutes.
Perform this routine a few times each day.
Eat soft foods.
Eat soft foods such as yogurt, mashed potatoes, cottage
cheese, soup, scrambled eggs, fish, cooked fruits and
vegetables, beans and grains. In addition, cut foods
into small pieces to decrease the amount of chewing
required. Avoid hard and crunchy foods (like hard rolls,
pretzels, raw carrots), chewy foods (like caramels and
taffy) and thick and large foods that require your mouth
to open wide to fit.
Take medications. To relieve muscle pain and
swelling, try nonsteroidal anti-inflammatory drugs
(NSAIDs), such as aspirin or ibuprofen (Advil, Motrin,
Aleve), which can be bought over-the-counter. Your
dentist can prescribe higher doses of these or other
NSAIDs or other drugs for pain such as narcotic pain
relievers. Muscle relaxants, especially for people who
grind or clench their teeth, can help relax tight jaw
muscles. Anti-anxiety medications can help relieve
stress that is sometimes thought to aggravate TMD.
Antidepressants, when used in low doses, can also help
reduce or control pain. Muscle relaxants, anti-anxiety
drugs and antidepressants are available by prescription
Low-level laser therapy. This is used to reduce the
pain and inflammation as well as increase range of
motion to the neck and in opening the mouth.
Wear a splint or night guard. Splints and night
guards are plastic mouthpieces that fit over the upper
and lower teeth. They prevent the upper and lower teeth
from coming together, lessening the effects of clenching
or grinding the teeth. They also correct the bite by
positioning the teeth in their most correct and least
traumatic position. The main difference between splints
and night guards is that night guards are only worn at
night and splints are worn full time (24 hours a day for
7 days). Your dentist will discuss with you what type of
mouth guard appliance you may need.
Undergo corrective dental treatments. Replace
missing teeth; use
braces to balance the biting surfaces of your teeth
or to correct a bite problem.
Avoid extreme jaw movements. Keep yawning and
chewing (especially gum or ice) to a minimum and avoid
extreme jaw movements such as yelling or singing.
Don't rest your chin on your hand or hold the
telephone between your shoulder and ear. Practice good
posture to reduce neck and facial pain.
Keep your teeth slightly apart as often as you
can to relieve pressure on the jaw. To control clenching
or grinding during the day, place your tongue between
Learning relaxation techniques to help control
muscle tension in the jaw. Ask your dentist about the
need for physical therapy or massage. Consider stress
reduction therapy, including biofeedback.
More Controversial Treatments
When the basic treatments listed above prove unsuccessful,
your dentist may suggest one or more of the following:
Transcutaneous electrical nerve stimulation (TENS).
This therapy uses low-level electrical currents to
provide pain relief by relaxing the jaw joint and facial
muscles. This treatment can be done at the dentist's
office or at home.
Ultrasound treatment is deep heat that is applied to the
TMJ to relieve soreness or improve mobility.
Trigger-point injections. Pain medication or anesthesia
is injected into tender facial muscles called "trigger
points"" to relieve pain.
Radio wave therapy. Radio waves create a low level
electrical stimulation to the joint, which increases
blood flow. The patient experiences relief of pain in
-back to top-
Surgery should only be considered after all other treatment
options have been tried and you are still experiencing
severe, persistent pain. Because surgery is irreversible, it
is wise to get a second or even third opinion from other
There are three types of surgery for TMD: arthrocentesis,
arthroscopy and open-joint surgery. The type of surgery
needed depends on the TMD problem.
This is a minor procedure performed in the office under
general anesthesia. It is performed for sudden-onset,
closed lock cases (restricted jaw opening) in patients
with no significant prior history of TMJ problems. The
surgery involves inserting needles inside the affected
joint and washing out the joint with sterile fluids.
Occasionally, the procedure may involve inserting a
blunt instrument inside of the joint. The instrument is
used in a sweeping motion to remove tissue adhesion
bands and to dislodge a disc that is stuck in front of
the condyle (the part of your TMJ consisting of the
"ball" portion of the "ball and socket")
Patients undergoing arthroscopic surgery first are given
general anesthesia. The surgeon then makes a small
incision in front of the ear and inserts a small, thin
instrument that contains a lens and light. This
instrument is hooked up to a video screen, allowing the
surgeon to examine the TMJ and surrounding area.
Depending on the cause of the TMD, the surgeon may
remove inflamed tissue or realign the disc or condyle.
Compared with open
surgery, this surgery is less invasive, leaves less
scarring, and is associated with minimal complications and a
shorter recovery time. Depending on the cause of the TMD,
arthroscopy may not be possible, and open-joint surgery may
Open-joint surgery. Patients undergoing open-joint
surgery also are first given a general anesthesia.
Unlike arthroscopy, the entire area around the TMJ is
opened so that the surgeon can get a full view and
better access. There are many types of open-joint
surgeries. This treatment may be necessary if:
The bony structures that comprise the jaw joint are
There are tumors in or around your TMJ
There is severe scarring or chips of bone in the
arthroscopy, open-joint surgery results in a longer healing
time and there is a greater chance of scarring and nerve
Also called Recurrent Apthous Stomatitis or Apthous Ulcers.
Its unfortunately common disease characterized by development
of painful, recurring solitary or multiple ulcerations of the
of oral mucosa.
Numerous possible causes have been suggested and these include
Bacterial infection, Immunological abnormalities, nutritional
deficiencies such as Iron, Vitamin B12 or Folic Acid.
Precipitating Factors preceeding outbreak of Apthous Ulcers
inlcude Local Trauma such as self-inflicted bites, oral surgical
procedures, needle injections and dental trauma. Factos such as
Endocrine conditions also exist. Most series show that the
incidence is greatest during the premenstrual period. Many patients
with Apthous Ulcers have a history of asthma, hay fever or drug
Treatment. There is no specific treatment, over the years many
drugs have been advocated. Although, it was found that Tetracycline
mouthwash(250 mg) used four times daily for 5 to 7 days produced a
good response in nearly 70% of the patients by relieving pain,
reducing the size of the lession and reducing the healing time.
An steriod ointment applied locally also showed effectiveness.
Apthous Ulcer or Canker sores are often confused with Cold Sores
or also called Herpes Labialis or fever blister. Although they are
not the same. Cold sores, are groups of painful fluid-filled
blisters. Unlike canker sores, cold sores are caused by a virus
and are extremely contagious. Also, cold sores typically appear
outside the mouth – usually, under the nose, around the lips, or
under the chin while canker sores occur inside the mouth.
BREATH OR HALITOSIS
What Is It?
Bad breath is breath that has an
unpleasant odor. It's also known as
halitosis. This odor can strike from
time to time, or it can be long-lasting,
depending on the cause.
Millions of bacteria live in the mouth,
particularly on the back of the tongue.
In many people, they are the primary
causes of bad breath. The mouth's warm,
moist conditions are ideal for the
growth of these bacteria. Most bad
breath is caused by something in the
Some types of bad breath are considered
to be fairly normal. They usually are
not health concerns. One example is
"morning mouth." This occurs because of
changes in your mouth while you sleep.
During the day, saliva washes away
decaying food and odors. The body makes
less saliva at night. Your mouth becomes
dry, and dead cells stick to your tongue
and to the inside of your cheeks. When
bacteria use these cells for food, they
produce a foul odor.
In addition, bad breath can be caused by
Poor dental hygiene -
Infrequent or improper brushing and
flossing, which allows bits of food
to decay inside the mouth
Infections in the mouth -
Periodontal (gum) disease
Respiratory tract infections -
Throat, sinus or lung infections
External agents - Garlic, onions,
coffee, cigarette smoking, chewing
Dry mouth (xerostomia) - Caused by
salivary gland problems, medicines
or "mouth breathing"
Systemic (bodywide) illnesses -
Diabetes, liver disease, kidney
disease, lung disease, sinus
disease, reflux disease and others
Psychiatric illness - Some people
may believe they have bad breath,
but others do not notice it. This is
referred to as "pseudohalitosis."
You may not always know that you have
bad breath. That's because
odor-detecting cells in the nose
eventually get used to the smell. Other
people may notice and react by recoiling
as you speak.
Other symptoms depend on the
underlying cause of bad breath:
Poor dental hygiene - Teeth
are coated with film or plaque. You
may have food trapped between the
teeth and pale or swollen gums.
Infections in the mouth - Symptoms
depend on the type of infection.
They can include:
Red or swollen gums that may bleed
easily, especially after brushing or
Pus between teeth or a pocket of pus
(abscess) at the base of a tooth
Loose teeth or a change in how a
Painful, open sores on the tongue or
Respiratory tract infections - Sore
throat, swollen lymph nodes ("swollen
glands") in the neck, fever, stuffy
nose, a greenish or yellowish nasal
discharge, a mucus-producing cough
External agents - Cigarette stains on
fingers and teeth, a uniform yellow
"coffee stain" on teeth
Dry mouth - Symptoms may include:
Difficulty swallowing dry
Difficulty speaking for a
long time because of mouth
Burning in the mouth
An unusually high number of
Dry eyes (in Sjögren's
Systemic (bodywide) illnesses -
Symptoms of diabetes, lung disease,
kidney failure or liver disease
A dentist or physician may notice bad
breath during an office visit.
Sometimes, the smell of the patient's
breath may suggest a likely cause for
the problem. For example, "fruity"
breath may be a sign of uncontrolled
diabetes. A urine-like smell, especially
in a person who is at high risk of
kidney disease, can sometimes indicate
Your dentist will review your medical
history for conditions that can cause
bad breath and for medicines that can
cause dry mouth. Your dentist also will
ask you about your diet, personal habits
(smoking, chewing tobacco) and any
symptoms. He or she also will ask who
noticed the bad breath and when.
Your dentist will examine your teeth,
gums, mouth and salivary glands. He or
she also will feel your head and neck
and will evaluate your breath when you
exhale from your nose and from your
Your dentist may refer you to your
family physician if a bodywide illness
is the most likely cause. In severe
cases of gum disease, your dentist may
suggest that you see a periodontist
(dentist who specializes in gum
You will need diagnostic tests if the
doctor suspects a lung infection,
diabetes, kidney disease, liver disease
or Sjögren's syndrome. The type of tests
you get depends on the suspected
illness. You may get blood tests, urine
tests, X-rays of the chest or sinuses,
or other tests.
How long bad breath lasts depends on its
cause. For example, when the problem
results from poor dental hygiene, proper
dental care will begin to freshen the
mouth right away. You'll have even
better results after a few days of
regular brushing and flossing.
Periodontal disease and tooth abscess
also respond quickly to proper dental
Bad breath caused by chronic sinusitis
may keep coming back, especially if it
is caused by a structural abnormality of
Bad breath that results from a systemic
illness may be a long-term problem. It
often can be controlled with proper
Maintaining good oral health is
essential to reducing bad breath.
Schedule regular dental visits for a
professional cleaning and checkup. If
you think you have constant bad breath,
keep a log of the foods you eat and make
a list of medications you take. Some
medications may play a role in creating
mouth odors. Let your dentist know if
you've had any surgery or illness since
your last appointment.
Brush twice a day with fluoride
toothpaste to remove food debris and
plaque. Brush your tongue, too. Once
a day, use floss or an interdental
cleaner to clean between teeth.
Mouthwashes are generally cosmetic
and do not have a long-lasting effect on
bad breath. If you must constantly use a
breath freshener to hide unpleasant
mouth odor, see your dentist. If you
need extra help in controlling plaque,
your dentist may recommend using a
special antimicrobial mouth rinse. A
fluoride mouth rinse, used along with
brushing and flossing, can help prevent
You also can combat bad breath by
drinking plenty of water every day to
help your body make saliva. An
occasional swish of the mouth with water
can loosen bits of food. Other products
can help you keep breath fresh and
prevent plaque from forming. They
Sugarless breath mints
The treatment of bad breath depends on
Call your dentist promptly if you have
bad breath with loose teeth or painful,
swollen gums that bleed easily. Also,
call your doctor if you have bad breath
along with any of the following
Even if you have none of these symptoms,
call your dentist or physician if your
bad breath continues despite a good diet
and proper dental hygiene.
Bad breath may be the sign of a
medical disorder, such as a local
infection in the respiratory tract,
chronic sinusitis, postnasal drip,
chronic bronchitis, diabetes,
gastrointestinal disturbance, liver or
kidney ailment. If your dentist
determines that your mouth is healthy,
you may be referred to your family
doctor or a specialist to determine the
cause of bad breath.