Temporomandibular Disfunction (DTM) is an alteration of the structures that integrate the temporomandibular joint (TMJ). Also knows as TMJ Disfunction.

TMJ is the joint that allows jaw mobility. These movements are necessary in the making of specific activities such as chewing, talking, swallowing, etc.

TMJ is a complex joint. Is composed of bone, muscle and joint structures.

The bone structures that compose TMJ are the jaw and the skull bone called temporal (therefore the name temporomandibular).

The muscular structures are all the muscles that are involved in the jaw's movements.

The joint structures are the ones that make up this particular joint and they are: the disc joint, the synovials, the joint's ligaments, and the capsule joint.

There are two TMJ's: right and left, having the specific quality of working both simultaneously in each jaw movement.

There is not a specific cause for temporomandibular dysfunction. It is a multifactor syndrome, meaning there are multiple factors, called contributing factors, which are involved in TMD's genesis. These contributing factors are:

• Genetic predisposition

• Dental Malocclusion

• Wisdom teeth included

• Bruxism (habit of grinding or tightening the teeth)

• Anxiety, stress, depression

• Postural habits

• Sleep disorders

The symptoms are multiple and are in direct relation to the joint structures altered.

• TEETH AND MOUNTH
  • Tightening or grinding the teeth (Bruxism)
  • Loose or fragile teeth perception
  • Uncomfortable Chewing
  • Dry mouth
  • Hot or scalded mouth

• MANDIBULAR PROBLEMS
  • Joint noises or snaps
  • Jaw muscle pain
  • Limitation in the mouth's openness
  • Jaw displacement while opening mouth
  • Dislocations or blocks while opening or closing mouth
  • Impossibility to open mouth without forcing it
  • Painful sensibility or swollen muscles

• FACIAL PAIN OR HEADACHE
  • Frontal area headaches
  • False migraine
  • Nasal obstruction or sinus pain
  • Pain in the back or top area of the head
  • Very sensible scalp
  • Tingling or pressure sensation in the face

• EYES
  • Ocular pain or behind the eyes
  • Light sensibility (photophobia)
  • Alter vision

• EAR
  • Noises
  • Loss of hearing
  • Earache (no for infection)
  • Itching
  • Vertigo

• THROAT
  • Burning, inflammation, congestion
  • Constant felling of swelling
  • Difficulty swallowing

• NECK AND BACK
  • Pain, rigidity, muscular inflammation
  • Reduced mobility

• OTHER SYMPTOMS
  • Tingling sensation in arms and hands
  • Fatigue
  • Depression

TMD's diagnose is based on the presence of different symptoms, such as the ones described before, and other complementary tests.

The most frequent complementary test are X-rays and magnetic resonance (MRI).

Firstly and most important, is to find the contributing factors present that influence TMD to eliminate them, if possible.

Basically, there are four types of treatment that, based on the diagnosis, can be applied.

• Physical Treatment
• Drug Treatment
• Psychological Treatment
• Interoral appliances: Oclussal Splint

FISICAL TREATMENT

• Thermo therapy: cold and hot
• Freezing sprays
• Physiotherapy
  • Massages
  • Exercises
• Transcutanius electrical nerve stimulation (TENS)
• Ultrasound

DRUG TREATMENT

• Painkillers
• Antiflammatories
• Anesthetics
• Muscle Relaxers
• Anxiolitics
• Antidepressives

PSYCHOLOGICAL TREATMENT

In those cases where the contributing factors are psychic based (anxiety, depression) are very important to examine the case thoroughly and dominate the syndrome.

OCLUSSAL SPLINT

In the cases where the habit of tightening or grinding the teeth (bruxism) is observed exists as a contributing factor, then mouth molds are taken and an intraoral appliance, called a oclussal splint, is built in Dental Laboratory.

This oclussal splint is then, generally, adjusted to the patient's upper arch.

The best prevention against temporomandibular dysfunction is high control on the contributing factors. A very important key is the premature diagnosis of these contributing factors.

All cases must be individualized and personalized, but in general terms and according to the contributing factors present there are several options:

• Dental Malocclusions: orthodontic treatments
• Presence of wisdom teeth: surgical extractions
• Bruxism: daily habit control or nightly oclussal splint
• Anxiety, stress, depression: relaxation, psychotherapy, psychiatric treatments and drug treatments
• Postural Habits: postural habits modification
• Sleep disorders: study and treatment

In cases where ATM dysfunction is already installed the following techniques are recommended:

• Avoid wide mouth opening
• Chewing with both sides of the mouth
• Eating food in small portions
• Muscular relaxation exercise

The consequences of bruxism are multiple, being the most important:

• Dental wear
• Muscle pain and spasms
• Temporomandibular joint dysfunction
• Headache
• Loss of the facial esthetics
• Dental sensitivity
• Phlegmons
• Dental movements and fractures
• Sleep alterations

There are two types of bruxism and they can appear simultaneously:

• Daily
• Nightly  

Daily bruxism is the habit of tightening the teeth during the day, especially in highly emotional situations. This is very harmful to the muscular structures and it can lead to spasm and muscle pain.

Nocturnal bruxism is the habit of grinding the teeth while asleep. It is particularly damaging for the dental structures since it leads to dental wear.

In the first place, the most important part is an early diagnosis. The sooner bruxism is detected, the more consequences that can be avoided.

Since anxiety and stress are important factors in keeping this habit, some sort of psychotherapy should be recommended for stress or anxiety control.

The specific treatment will depend on the type of bruxism.

Treatment for Daily Bruxism

In this case some kind of habit control by the patient is recommended. The patient has to be mentally aware of the moments in which he finds himself grinding his teeth. This could happen while driving a car, at work, at home, etc.

When this occurs the patient must substitute this habit for a less harmful movement.

For example, to place the tip of the tongue on the palate, this is a relaxed mandibular position that counterfeits the harmful effects of grinding.

For this case, the use of an intraoral appliance called oclussal splint is recommended.

Just as we indicated before, to do this, a model of the mouth is taken, and then the oclussal splint is made using acrylic resin and later adapted to the upper arch.

The splint should be used overnight, during sleep.

The goal of the oclussal splint is, that even though the patient continues with the habit of tightening his teeth, the teeth will not wear out; instead the acrylic splint is worn out.

The consequences of dental wear by nightly bruxism fades away after the oclussal splint's first use, and with time the habit of grinding the teeth will also fade away.

BIBLIOGRAPHY:

• Evaluación, diagnóstico y tratamiento de los problemas oclusales. Peter E. Dawson. Ed. Salvat 1991
• Oclusión. Abjean Korbendau. Ed. Panamericana 1980
• Medicina Bucal; Antonio Bermejo Fenoll. Ed. Síntesis 1998
• Atlas de Patología Oral; Peter Reichart. Ed. Masson 2000
• Tratado de Odontología; Antonio Bascones; Ed. Trigo 1998
• Bonica JJ. The management of Pain. Ed 2. Philadelphia: Lea & Febiger, 1990: 169-174
• Okeson JP. Bell's Orofacial Pains. Quintessence Publishing Co, Inc. Carol Stream, Illinois. 1999
• Travell JG, Simons DG. Myofascial Pain and Disfunction. Baltimore, Md: Williams & Wilkins 1992