In most cases, when the MRI is ordered of the TM joints, it is patently clear when there is cortical erosion of either the condyle or the fossa (socket for the condyle). The radiologist will most likely indicate that the articular disc (that protects the condyle) is displaced and thus the condyle is now exposed and is bone on bone in the fossa. This is not a good situation and can lead to all sorts of pain, asymmetry, and other problems in the head/neck region. Think of it like this: If the disc is slipped off the top of the condyle, it can no longer protect your condyle from banging into the socket bone-on-bone. Diagnosis: OUCH!

The cortical erosion of the condyles and fossas can also be diagnosed with the X-ray called CBCT (Cone-Beam Computed Tomography). The CBCT allows the dentist or the radiologist to look very precisely at the condyle and fossa and if erosion has begun it can be clearly seen in the images. Even though some people do not like taking the CBCT due to the radiation, it is really important to do these images every few years to follow up on the cortical erosions.

So, what does one do when cortical erosions are present? Well, in most cases it’s called ‘watchful waiting’ where the doctor checks the range of motion on a regular basis to make sure the erosions are not doing more obvious damage. You should wear your mouth appliance(s) accordingly to protect the joints. And every few years, just re-take the images and compare them to the previous images.

Unfortunately, if things worsen, surgery is sometimes all that is left to offer to a person with severely damaged joints. There are several types of surgery. The simplest surgery is called plication of the articular discs. This means just moving the slipped discs back into the proper position to reduce the risk of bone-on-bone damage to the condyle and fossa. The next level of surgery entails what is called menisectomy – removal of the damaged discs. If the discs are fully removed, this enhances the risk of bone-on-bone, condyle to fossa, banging or pounding. As long as the appliance (splint) is worn, this is not a problem. Unfortunately, if things get worse, then TJR (Total Joint Replacement) is indicated. This is a big surgery but very rarely indicated.

As with most health issues: Treat early and keep a careful watch on your health!

The post So, What Is Cortical Erosion? first appeared on Sleep & TMJ Therapy.

Diagnosis of the problem is paramount. A really well-done MRI is critical in determining the path of treatment, and many times getting good imaging is quite difficult. So here is the first ‘delay’ in fixing the problem, getting an appointment for a well done and well-read MRI. It can take several weeks to get that appointment and quite honestly some people just do not want to wait. I can’t blame them either. Let’s get it done now!

The next delay is just getting an appointment at the office to discuss all the issues. This is where we look at the bone from the CBCT X-ray and the soft tissue from the MRI. In most cases, people want their insurance to pay at least something and that in turn creates the next delay. Next on our list is the fact that with TMJ appliances, they are custom-made. This takes time. They are not something sitting on the shelf, ready to put in the mouth. It takes weeks to make them since they are custom made for each person.

Now let’s get to the next big delay. You have to wear the devices for 12-18 months to give the discs a chance to move back into the proper position. That’s right folks, it takes that long, especially if the discs have been displaced for several years. The discs don’t just fall back into place instantly. It will take time and patience. Of course, some are not willing to devote such time (and patience) to their health, so they do not do anything. That is OK as not everyone is experiencing the same level of pain or discomfort. When it gets really bad, the patient will pursue treatment but generally now the problem is harder to fix, costs more, and takes more time. This is like most things in life.

Finally, the biggest time consumer of all – finishing after the discs are back in place. In most cases, orthodontic work is needed to grow the teeth taller to protect and support the TM joints (the jaw joints). Orthodontics can take 1 ½ -3 years, easily! So here you are, having spent all this time on appliances only to realize it’s going to take another couple of years. You are basically dedicating up to 4-5 years of your life toward fixing a TMJ problem. This is why we always tell our patients phase one is appliance therapy and phase two is finishing. Thus, the question has been answered. Now you know why TMJ treatment can take so long!

The post The Case of: “Why Does This Take So Long?” first appeared on Sleep & TMJ Therapy.

Another aspect of having a tooth pulled out is that upon removal of the tooth, the bite on that side will experience an almost immediate collapse in which the jawbone (condyle) will now go more deeply into the socket. This is where a TMJ problem begins. When that condyle jams further up into the jaw socket, it will impinge on the articular disc that covers the condyle. This can cause a gradual displacement of the disc and subsequent TMJ disorder. If multiple teeth are removed this can readily lead to the discs being pushed way out of proper placement and this can be quite painful for so many people.

With periodontal disease, the bone and gum support around the tooth becomes weaker over time. This can lead to the tooth getting loose in the socket and it can no longer be a good vertical support for the jaw joints. Just like the foundation of a house, if it starts to rot away, the whole house can tip sideways. The jaw is similar. If the teeth become looser due to periodontal disease, this can destabilize the jaw joints and the discs in those joints can become damaged more readily. By maintaining good periodontal support for your teeth, this will help the jaw joints stay healthier and stronger.

Unfortunately, oral cancer should be mentioned in this blog. Cancer in the mouth can lead to loss of teeth and bone which of course can lead to loss of TMJ support. This is why it is so important to keep up with your dentist and at least yearly have them do an oral cancer screening. This screening only takes a few minutes, yet it could save your life and your health. So many people are very afraid of cancer but if detected early enough it is fairly easy to treat.

As Dental Health awareness month is April, be smart and reach out to your dentist about your dental health. Ask questions. Ask if they are checking for periodontal disease. Ask about cavities. And most importantly, ask if they are checking for any signs of oral cancer or other diseases.

The post How Oral Health Affects the TM Joints first appeared on Sleep & TMJ Therapy.

In the past, it was quite common for an orthodontist to order extractions of perfectly good teeth to make the process of moving teeth and creating space with the use of braces easier. So many children are now presenting with narrow arches and crowded teeth that it made sense (somewhat) to remove the crowded teeth, thus allowing the orthodontic work to go faster and easier. But somewhere along the way a few practitioners noticed that the removal of the bicuspid teeth would often cause the upper and lower jaws to collapse backward which would lead to a collapsing of the airway as well. They also rather astutely noticed that the palate would become smaller, which made breathing more difficult as well. There are still orthodontists today who practice the method of extracting the teeth to make room and the braces go easier. However, many more are learning that there just might be better techniques.

The extractions of impacted teeth are a completely different need but also can cause the same issue. In this situation, the teeth need to be removed because 1) the lack of space in the bone means the teeth cannot erupt or 2) the tooth is growing in the wrong direction or position. In this situation, the stress placed on the jaw joint can cause the disc to be displaced and in addition, put a strain on the muscles around the jaw joint.

Of course, another method of expansion is the good old-fashioned RPE (Rapid Palatal Expander), but even this has its issues. The RPE will often just open the palate rapidly and the midline suture might not form into solid bone — it might just be a cartilaginous suture that can move around over time. This would not be very effective. The reason is on a skeletal level this instability can cause changes and distortions in the cranium. Another approach to getting some expansion is to use the ALF appliance as much as possible with the understanding that a few months with the RPE might be OK.

Another problem that is frequently seen among dentists, pulling out bicuspids, which makes the upper and lower jaws move and therefore are no longer in the same position as previously. This change can affect how the condyles (top of the jawbone) fit into the sockets and in turn, can lead to a TMJ problem. When that condyle is re-positioned after extractions, it will no longer be in the same relationship to the disc that covers it. The disc can end up displaced over time. This is what can lead to head and neck pain. So many extraction patients end up with similar problems later in life.

There are some practitioners who will actually use a palatal expander to re-open the extraction spaces to put in dental implants to ‘restore’ what was taken away. This is actually a controversial topic. As we get a bit older, the bones in the skull do indeed become more solid and if you were to try expansion a lot — like the width of a bicuspid that had been removed — it might be too much for the body to handle. Does that make sense? It might be that the expansion is just too much of a  ‘stretch’ and moving bones around might lead to more pain. This is another reason why the more conservative practitioners would use the ALF appliance to get as much gentle expansion as possible while minimizing trauma to the facial bones.

So, in general, extractions for the sake of doing braces may not be the best idea. Be sure to be careful when considering this.

The post Are Teeth Extractions Helpful? first appeared on Sleep & TMJ Therapy.