Kinkease Use and Uses: November 2008

November 15, 2008

Alternative Therapy Approach to TMJ Pain

Pain due to inflammation of the temporo-mandibular joint (TMJ) can be one of the most miserable conditions to experience and it is certainly one of the most difficult conditions to treat.

By the time the patient is referred to this office, most of the traditional approaches have been tried. these include:

Splinting
Oral narcotics
Oral anti-inflammatories
Muscle relaxants
Anti-depressants
(hopefully this one has not been done yet) Surgery to the TMJ.
Transdermal medication delivery.

Each of these approaches has advantages, disadvantages, proponents and critics.

1. Splinting sometimes works, but it tends to be expensive, transient in effect. Minimally invasive in nature, it rarely causes further damage, but it can be an expensive approach to try. Effective in approximately 10% of TMJ sufferers, it is hard to get too excited about using it routinely.

2. Oral narcotics are effective in treating the pain, but pain-killers, by nature, do not deal with the underlying structural problem, nor do they deal with the inflammation and muscle spasm that accompany TMJ pain. Further, the effects are transitory and narcotics should be used periodically, or in a pulse-type application, to prevent habituation and maintain therapeutic effect. Opiates are best used in conjunction with muscle relaxants and anti-convulsants.

3. Oral anti-inflammatory medications are helpful to deal with the inflammatory portion of the TMJ symptom complex. NSAID's, as they are often called, work differently on different patients, and there is somewhat of a trial and error process to find the right NSAID for any individual patient. NSAIDS have side-effects, and these side-effects must be recognized and treated. Gastro-intestinal problems are common, and if the patient tolerates the first 3 to 4 weeks, generally they will tolerate long-term use.

4. Muscle relaxant use is essential to treat the patient with TMJ. As a result of the inflammation of the joint, the masseter and temporalis muscles will go into spasm. This increases tension across the joint which in turn increases compressive forces on the cartilage within the joint. Deformation of the meniscal cartilage prevents normal joint function, and relaxation of the muscle is essential for symptom management and restoration of function. The splints work here, as well.

5. Anti-depressants have a place in the treatment of TMJ for a number of reasons. First, sleep disorder is common as a result of the pain, gritting of the teeth and headache. This sleep deprivation leads to depressive symptoms in as little as one week. Anti-depressants assist with the secondary depression, but clever choice of the anti-depressant medication will result in secondary analgesia as well as secondary muscle relaxant choices.

6. TMJ surgery seems to be helpful in a small minority of patients. This is a therapy of last resort.
Expensive and largely ineffective, patients tend to shy away from this option.

7. Transdermal medication delivery is a very effective approach to treating TMJ. There are several very useful medications for treating TMJ, and each patient is different in response.