16 Aug Treatment for Temporomandibular Disorder (TMD): Surgery vs Non-surgery Approaches
I have been asked for years to start blogging about topics that pertain to what I help patients with: orofacial pain and obstructive sleep apnea. I have constantly been dodging the requests because I was the one in school that never cared much for writing or creative writing. Let’s face it…I am a dentist. English would rarely be the focus of a person pursuing a career in the health field. We are more of the science and math type.
TMD
However, I give credit for this first blog to a group of wonderful women in my Lifegroup at church. This one is for the ladies who had such smart questions the other day about TMD and headaches. I simply felt caught off guard and could not answer them properly. To tell the truth, I did the worst job answering these questions because I felt so overwhelmed. You see, I have been missing in action from Birmingham and church for the last 2 years. I have been constantly traveling to conferences and taking board certifications in Orofacial Pain and Dental Sleep Medicine. All this information, suddenly loaded into my brain, has made it hard for me to carry on a normal conversation in social settings. These ladies’ questions were not too hard for me to answer. I just didn’t expect so many incredible questions coming at me all at once.
One of their biggest questions was: how do we treat TMD and why not just have joint surgery? Well, for us orofacial pain specialists this is a very complicated question. Without having the specific patient case in front of us, it is difficult to answer outright. Every case is different. So, let me see if I can give a generic explanation.
Temporomandibular disorder (TMD) can be a primary disorder (meaning it is directly coming from the joint) or it can be a secondary disorder (meaning it is a site of pain and not the source of pain). Primary TMD can be diagnosed by giving anesthesia to one of the nerves which innervates the joint that is called the auriculotemporal nerve. If the patient’s pain is completely eliminated, then we know it is primary TMD. Primary TMDs are not seen as commonly as secondary TMDs.
If primary TMD is the diagnosis, we start with splint therapy according to which type of primary TMD the patient presents. We might also send the patient to physical therapy. In Birmingham, we have two physical therapists that have taken specialized courses in TMD beyond their training in PT school. This is the equivalent of me taking specialized courses in TMD beyond my training in dental school. If therapy does not completely eliminate the pain, then we refer our patient to the talented oral surgeons in Birmingham who perform surgery on the joint. As with all medical procedures dealing with muscle and joint pain, therapy is always tried first and surgery second. We always want to try the least invasive thing first.
What about secondary TMD? What is secondary TMD? Secondary TMD is when you have TMD but it is your site of pain and not your source of pain. We see patients commonly being treated for primary TMD when they actually have secondary TMD. That is why TMD treatment is not working for their problem. One of the common causes of secondary TMD is headaches. This is very complicated to explain. The best way I know how to explain it is as follows: the muscles which move your jaw are innervated by the same nerve where headaches are derived.
Branches of the trigeminal nerve feed the muscles of your jaw and other branches of the trigeminal nerve feed the vasculature in the meninges around your brain. All of the branches come together and feed into your brainstem into an area known as the trigeminal brainstem complex. In this complex, there can become confusion in these nerves. Therefore if the nerves feeding your headaches give a crossed up message to the nerves feeding your jaw muscles, your jaw becomes a site of pain vs the source of pain. What do we need to do? We need to treat the headache. Why is this so hard?
One of the ladies in my Lifegroup brought up the point she had TMD as a young adult. She had jaw surgery and it proved to be very effective for her. So therefore she probably had primary TMD. However, she is currently a headache sufferer. She is more likely to develop secondary TMD due to the chronic headaches. Again, why in the past has this been so hard to treat? Birmingham does not currently have a neurologist that is a headache pain specialists and until recently Birmingham has not had an orofacial pain specialist. Birmingham has very talented neurologists but they are in high demand for other neurological needs. This does not allow them to focus specifically on headaches.
So how can these patients be treated? When they have pain presenting in the orofacial region, I work to get them a proper diagnosis of the source of pain. After the diagnosis is made, we start treatment. If medications are needed for a period of time, I work with the local neurologists or the patient’s primary care physician for them to manage these medications. Hopefully, in the near future and if I have any influence on the matter, Birmingham will have a neurologist that is a headache specialist to help other neurologists and I treat our patients.
Here at TMJ & Sleep Solutions of Alabama, we also focus on the TMD patient’s sleep to make sure they are keeping it properly maintained. Why is sleep so important for TMD and headaches? I always say “Sleep feeds pain and pain feeds sleep”. If you are not able to get proper sleep, then your body is not able to repair itself. Some people believe they get plenty of sleep but they are still chronically tired. This is their body’s way of telling them something is not allowing them to get in the proper stages of sleep to repair their bodies. At TMJ & Sleep Solutions of Alabama, we try to get to the source of the chronic fatigue so we can help their body repair itself.
I hope this post enlightens the public as to when we perform surgery for TMD and when we do not. I feel so blessed to be in Birmingham where we have talented oral surgeons and neurologists to help with these specific medical issues. I also hope this helps people understand just what we can do at TMJ & Sleep Solutions of Alabama to help them with their orofacial pain. TMD is not the only orofacial pain we treat. We also work with the neurologists to treat other neuropathic pains of the face. I will elaborate more on those in a future blog post.