TMJ and Bite Issues
Your temporomandibular joint (TMJ) works similarly to a sliding hinge, connecting your jawbone to your skull. If you suffer from a TMJ or a bite disorder, you may experience significant discomfort in the jaw joint region, located just in front of your ear. In the vast majority of cases, TMJ pain is actually muscle fatigue caused by teeth hitting out of their proper position or order. The key to the successful long-term resolution of TMJ discomfort is adjusting the bite precisely, to function how Mother Nature intended the upper-body musculature to function.
It is highly ineffective to attempt to adjust the bite with only carbon paper, which is what virtually every dental office has done for the past century; such marks are accurate only about one in eight times. At Advanced Dental Arts NW, we rely on computerized data—confirmed with measurements of your muscle activity via EMG readings—to adjust your bite to an objective and measurable endpoint. We are the only Portland office accredited by the Center for Neural Occlusion to provide this service, using this equipment and technique.
To help our patients better understand the best course of care to relieve their discomfort, here are some answers to a few of the most common questions regarding the treatment of TMJ and bite disorders:
What is Disclusion Time Reduction?Disclusion Time Reduction (DTR) is a computer-directed process designed to adjust your bite by removing high-spot interferences that prevent free and easy tooth interactions that occur as you chew. In essence, DTR “fine-tunes” your teeth and muscles and the TMJ to continuously work together, comfortably and harmoniously.
Muscles and joints work most efficiently when they have minimal interferences that cause friction. No machine lasts long, or runs smoothly, if it must fight against friction, and teeth are no different. Friction causes the teeth to send messages to the muscles that tell those muscles to grind, and if that friction is another tooth, or teeth, or dental work, the muscles are grinding all the time. This puts a constant stress on the muscles, which build up lactic acid, and cause severe pain in the muscles, just like overworking muscles in a gym. The goal of DTR is to remove these interferences and to thus allow the muscles, teeth, and joints to work with less effort, energy, and fatigue so they can perform their jobs more efficiently and effectively.
How Do High Spot Interferences Impact My Jaw or Bite Health?If you have ever had a pebble in your shoe or a splinter in your finger, you know how a very small irritant can cause the other muscles to alter their normal routines. Your jaw is meant to move smoothly and with minimal resistance. Any “bumps” or restrictions cause the muscles to act less efficiently. They will try to either work around, or power through, or wear away, any obstacles that interfere with their normal operation. This can create a number of problems, including (but not limited to):
What Causes or Creates High Spot Interferences?Interfering contacts can arise from a variety of causes. Some develop naturally, some may occur due to a relatively minor childhood accident that occurs as the joints develop, and others can develop from significant trauma at any age. Many interferences are caused by orthodontic movements (braces or Invisalign®), and by the loss of teeth, which results in a tipping of the remaining teeth. Wisdom teeth can buckle the teeth out of position as well, or create problems if they come in tipped.
Dental restorations are a major cause of interferences because they are generally placed to restore a single tooth, and not as an integral part of the collective bite. In most instances, dental restorations are placed over the course of several years by different dentists, each slightly altering the overall bite of the patient. As a result, no one looks for the long-term, cumulative result those restorations have on how the patient’s teeth eventually come together.
Even a single tooth can cause big problems. If you’ve ever had soreness or pain with a new crown or filling, you already know firsthand what that can mean for the comfort of your bite.
I Thought Braces Were Supposed to Improve My Bite?Orthodontic treatment has a number of objectives. The eventual placement of the teeth depends on what’s possible within each patient’s mouth, the vision and mechanical abilities of the treating orthodontist or dentist, and the subjective opinions of esthetics and function. Unfortunately, how the teeth come together and function together often receives minimal attention at the end of treatment, when most patients are eager to have their braces removed or treatment completed. However, the bite remains a key to the long-term success and comfort of any orthodontic treatment.
I've Already Had My Bite Adjusted, Why Do It Again?Essentially every dentist will do some adjustment of the bite, but the questions always are: How did they determine what and where to adjust, and how did they measure it?
If the determination is made through biting on carbon paper, then it is inherently inaccurate. Studies have shown that even highly experienced dentists only correctly identify a high spot less than 13% of the time. This type of success rate is hardly acceptable for any type of established diagnostic procedure. But this is how essentially all dentists attempt to identify high spot interferences, simply because this is the way it always been done. Hardly a satisfactory justification.
With the use of computer analysis, the exact points of contact can be identified and then confirmed with the use of carbon paper. Because the T-Scan shows us where teeth are hitting, in what order, how hard, and throughout the chewing cycle, we have comprehensive information to work with that could not otherwise be ascertained. It is a highly accurate “movie” that clearly demonstrates the dynamics of how your specific bite functions. It is the difference between looking at a single still photograph of a dancer or watching a video of their entire routine: which method provides the more complete and informative basis for an opinion?
WHAT IS THE OBJECTIVE OF DTR?DTR has a measurable objective of guiding the back teeth out of contact when the jaw slides side-to-side, or to the front, by using the canines and incisors to direct the muscles. When your back teeth rub against each other, they trigger muscles in the face to redirect the jaw away from these restrictions, or to try to wear away the interferences. Over time, these muscles tire and become sore and painful. Subconsciously, you may even begin grinding your teeth in an effort to erode or break off the offending point(s). This behavior will not only further exhaust the muscles, it can also displace, break, or abrade your teeth. More importantly, it can cause permanent damage to the TMJ itself.
The key is to precisely remove the interferences and fine-tune the bite, so that your muscles function efficiently and comfortably. Because when muscles relax, so do you.
Is DTR the Same as Neuromuscular Dentistry?While the two fields do share some similarities, they also have some very important differences. DTR and NMD both focus on relaxing muscles that control your bite, but DTR assigns primary importance to how the teeth interact, while NMD looks first at the muscles. Additionally, the DTR bite is adjusted directly using real-time T-Scan analysis while concurrently monitoring muscle activity. This allows the procedure to be done in a far shorter amount of time.
NMD promotes the long-term use of mouth guards, while DTR doesn’t require the use of such appliances. With DTR, there is no need for TENS units, or headgear, or even models of your teeth, as with NMR, because all adjustments are done with the patient in their normal, natural bite. This works so well because the data is directly generated from the patient, without study models, TENS units, or cumbersome and seldom-reproducible headgear and magnets.
What Is the Difference Between Equilibration and DTR?There is a huge difference. Equilibration is a procedure in which the dentist selects where they determine your jaw should be, then works to put your bite on the back teeth. DTR, the polar opposite, works off your natural bite closure, and adjusts to direct the bite toward the front teeth, with the back teeth only hitting on full closure. Study after study documents the far superior results accomplished by DTR, while Equilibration has been performed for years with mixed results. Some traditions die hard—even in the face of something vastly more quantifiable and less subjective.
Will I Need to Wear a Splint or Mouth Guard After DTR?The avowed purpose of mouth guards and splints (athletic protection and sleep apnea aside) is to maintain a space between the teeth so no grinding or clenching occurs. However, there are several logical and physiological reasons not to use them.
Oral appliances are only beneficial when worn, which is rarely for most people. Night appliances, when they are worn, are worn for between 6 to 8 hours. This still leaves the majority of the day where they do not, and cannot, work. Daytime appliances are generally too cumbersome to be worn routinely, so the benefits are likewise questionable. But these obvious limitations still ignore some of the most important issues.
A mouth guard covers the biting surfaces of the teeth, thereby altering the bite. It may shield the teeth from direct contact, but it also creates a new bite, one that needs to be adjusted to make the muscles relax, just like your natural bite. Additionally, it opens and holds your bite to at least the thickness of the appliance. Unless you have an unnaturally over-closed bite (due ofttimes to tooth loss or extraction orthodontics), this spacing can have very negative effects on TMJ anatomy, and on the state of rest of the muscles themselves. That is why these appliances need periodic replacement: to compensate for what they have changed. It is a self-perpetuating problem.
One thing that mouth guards DO do is to change the chewing patterns, because the teeth now hit differently, and at different jaw heights. This in turn changes how the muscles respond, and when. The temporary relief people sometimes experience from such appliances is due not so much to the relaxation of the muscles as to the change in grinding patterns, which simply shift the stress and fatigue to different muscles or positions within the muscle groups.
Obviously, if you do not clench or grind (which is a key measurable objective of DTR), there is no benefit or need for an appliance to control those issues. Muscles in tune with the bite are happy and relaxed muscles, and have no incentive or purpose in grinding. After DTR, the vast majority of patients report that they feel better and more relaxed, and are told they no longer grind at night.
As a general rule, most mouth guards do far more damage than good. They are certainly cumbersome and inconvenient.
What About Orthodontic Retainers? Won’t My Teeth Shift Back if Not Retained?Any retainer that covers the biting surface of the teeth will affect the bite when worn. It adds thickness between the teeth, but it does nothing to protect the teeth when not worn.
The ideal retainer is one that does not affect the bite, and that would be what we call a “Hawley” appliance, which does not cover the biting surfaces at all. But this brings up a more interesting point. Teeth move only if there is a reason to move, and if you remove that reason (that unnatural force, if you will), well, the teeth should not want to shift since they have no incentive to do so. If you balance the bite, and you remove those unintentional forces, the teeth should largely and more comfortably, remain where they are.
We provide retainers after our orthodontic cases, but they act to retain the teeth in position only for several months. Our goal is to wean the patient from wearing them more than a few consecutive hours every week or two, simply to confirm that the teeth are not shifting subtly out of position. Hence, eventually we want the patient to use the “retainers” more as a monitoring system to alert us if the teeth are starting to shift, than as a method of holding the teeth in an unnatural and ultimately harmful position.
I Just Had Veneers and Crowns Placed, and My Dentist Said I Needed to Protect Them By Wearing a Mouth Guard.Again, from what are they being protected? Mouth guards are an insurance policy against them chipping and breaking because of grinding or bruxing, but that ceases to be a concern if the opposing teeth do not put unintended forces on them. Mouth guards provide a false security, in that they are there primarily to guard against breakage because the restorations were not placed with respect to the muscles, and sooner or later, the muscles are going to win. Most chipping and fracturing of teeth or restorations occur because of incidental excessive forces as you chew, and with DTR, these abnormal forces can be minimized.
If the bite is corrected with DTR, there is little chance of fracture from the bite. Unintentionally biting upon a small pebble, bone, or seed in food can always chip a tooth or restoration. However, since you’re unlikely to wear your mouthguard while eating, it wouldn’t make a difference.
How Long Will DTR Last?Teeth move in response to pressure. If the only forces applied are ideally oriented, the teeth should be pretty stable. That said, anything that changes the bite may affect this stability—this includes things like orthodontics, new dental work, tooth loss, and eruption of wisdom teeth. Habits like chewing on pencils should always be avoided. Otherwise, the stability of the adjusted bite is extremely good, and it may well last a lifetime.
Does This Negatively Affect My Teeth or Existing Dental Work?Depending upon the problem, there will be areas of some teeth that may be polished down to improve your bite. Whenever possible, we adjust the restored surfaces first, but we also polish down natural enamel if necessary. Generally, this is an extremely slight amount, measured in hundredths or tenths of a millimeter, but occasionally more. We avoid any area that is becoming sensitive.
One reason we prefer to adjust crowns and restored teeth instead of natural ones is that it is quite common that the restored teeth are the ones throwing the bite off because of their contours. If there is only a very thin layer of porcelain on a crown, for instance, it is possible that some metal base could be exposed. This should in no way weaken the function of the crown, and will likely greatly diminish the sensitivity on it.
At the end of an adjustment, we will polish all surfaces to make certain they are smooth and comfortable, without sharpness or roughness.
Do I Have to Get an Anesthetic Shot for DTR?DTR is usually performed without any numbing because the patient bites more naturally if they have full feeling. However, if one tooth is extremely sensitive, we might numb just that tooth for the initial adjustment. We would then do most of the adjustment in a following appointment when the tooth is more comfortable. This way you walk out of an appointment feeling better every time.
It is always surprising to patients that the teeth will frequently become far more comfortable as the bite is corrected. One of our favorite things is to offer a patient a glass of ice water immediately after their appointment, and watch their amazement as they find that the sensitivity is completely gone, for the first time in years.
Are the Effects of DTR Immediate?In the majority of cases, there is an instantaneous improvement in freedom of motion where the patient experiences the ability to chew comfortably, possibly for the first time. The effects on the muscles may be immediate, or it may take a few days to feel a noticeable improvement (“my jaw feels much better and my face is not as tight”) as the muscles recover from years of stress.
Pain associated with drinking ice water should be dramatically and rapidly diminished, sometimes within minutes. No more need to brush with desensitizing toothpaste, or to avoid iced beverages!
What If I Have More Questions?While the answers above are to some of the more commonly asked questions if you have any further concerns about Disclusion Time Reduction, please drop us an email at firstname.lastname@example.org, and we will happily answer you in a timely manner.
Dr. Teasdale is one of only a handful of dentists internationally to be certified as Level 1 at the Center for Neural Occlusion and has been a T-Scan user for more than 20 years. His background includes extensive training at the Las Vegas Institute for Advanced Dental Studies in both Restorative and Neuromuscular Dentistry, Orthodontic training through the United States Dental Institute and Invisalign®, Fellowship status in the World Congress of Minimally Invasive Dentistry, and extensive training in the use of clinical dental lasers and CAD/CAM Dentistry. He is in private dental practice in Portland, Oregon, at Advanced Dental Arts NW.