Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Greg Ness, who is here to discuss TMJ disorders surgical versus non-surgical treatments. Dr. Ness, thank you so much for being here.

Greg Ness: Hi, Bill. Thanks. I'm glad to be here today.

Host: Absolutely. Well, we are glad that you're here. So TMJ, this is something we hear about a lot of, but it would be good to really dive into this to understand what it really is. So, what is TMJ?

Greg Ness: Sure. So, when people say TMJ, they might be talking about what they think is a disease, but actually what they're referring to is the name of the temporomandibular joint, which is a mouthful, so you can see why the abbreviation is more popular. They're probably talking about what's one of a group of diseases called temporomandibular disorders or TMDs. TMD refers to not just joint disorders, but diseases of the muscles surrounding the joint as well. And in both cases, the major symptoms are pain with jaw movement and limited function, like being unable to chew normal foods.

Host: So, you get that pain or clicking in the jaw. Is that what we're talking about?

Greg Ness: You know, it can be anything from "My jaw is stiff and tired and hard to get open all the way" to "It hurts when I chew food" to "I can't get my teeth apart more than a finger-width."

Host: Oh, my goodness. Okay. So then, what causes TMJ disorders or TMD, as you were saying?

Greg Ness: The same diseases that can affect any other joint of the body can affect the TMJ as well. So, various kinds of arthritis, for example, are one whole family of diseases that impact the TMJ. Another frequent cause involves displacement or dislocation of the disc that's located between the jawbone in the socket that makes the other half of the joint.

So, it turns out the TMJs are as heavily used as any other joint in the body, even though they're not really weight-bearing joints. So, they sit in front of each ear where the jaw and skull meet. And the bony surfaces inside the joint are lined with a specialized cartilage, but they're also separated by a small shock-absorbing disc made of cartilage as well. And each person has two TMJs, one on either side of their jaw and one or both of them can be affected by disease. Now, the disc can be displaced and that can happen pretty commonly. And for most people, it's not a problem. They may notice some occasional popping or clicking noises in their joints when they move their jaw open, chew food. But in some cases, a displaced disc may cause pain when opening or closing or it can even limit jaw movement altogether. So, the disc can also get perforated or wear down to the point where there's an opening in it and it's a rough surface, which creates a gritty or grinding sound with joint movement.

Then, there are other problems that can happen to this joint like anything else. You can have trauma to the joint. You can have severe arthritis that can cause the bony parts of the joint to scar together or fuse and that prevents any kind of jaw movement at all.

Host: Basically, so trauma and rheumatoid arthritis, are those the main causes of this generally?

Greg Ness: I wouldn't say those are the main causes. I think that arthritis or probably, even if you want to get specific, synovitis, inflammation of the soft tissues in the joint is probably one of the more common problems. That can sometimes be related to that disc position or sometimes it seems to happen for reasons we don't really fully understand. That's probably the most common problem. The ones that are more severe that we treat as oral and maxillofacial surgeons more regularly end up being those conditions like arthritis where there's more of a surgical requirement to treat them.

Host: So, these symptoms can mimic other things as well. Is that why diagnosis sometimes can be difficult or why an OMS is perfect to diagnose this?

Greg Ness: Absolutely. It's also common for people to feel stiffness or pain in their jaw muscles. And that can be really similar to the kinds of pain you feel in the joints themselves. And that can be related to clenching or grinding your teeth together either during the day or during sleep and that causes pain, fatigue and stiffness in the muscles and difficulty moving the jaw. So, that's a diagnostic dilemma in many cases. And in some people, both occur and there's a combination of muscle and joint problems going on at the same time.

Host: A diagnostic dilemma.

Greg Ness: Correct.

Host: That makes sense. So, once it is diagnosed as TMJ, what are the possible range of treatments?

Greg Ness: Treatment of joint disease specifically can really range from dental, medical care to complex surgery. And depending on the diagnosis, you might start out with home care with short-term anti-inflammatory medicines, resting the jaw muscles and joints by eating only a soft diet and limiting how wide you open. And in some cases, muscle-relaxing medicines, bite planes or bite splint therapy or stress management counseling may be helpful.

Host: So, those are some of the easier methods of treatment.

Greg Ness: That’s the beginning for a lot of people.

Host: Okay. Got it. So then, where do you go after that?

Greg Ness: Well, the good news is those simple steps take care of the vast majority of the problems that people have. But when that doesn’t work and the TMJ is clearly the source of problems, surgery might be indicated. And then, that can either involve something like arthroscopy, which is much like you hear about athletes having on their knees or an open operation to repair the damaged tissues inside the joint by a direct surgical approach.

Host: So, most of the time, the first treatment, as you said, takes care of it. Then generally, if that doesn't work, then we're on to the potential surgical treatments.

Greg Ness: Correct. Although there are in a few specific cases, situations where the first line of treatment would be either a minimally invasive or an operation.

Host: Okay. So, that non-surgical method of treating TMJ, can you talk just a little bit more about that non-surgical method, exactly what that is? I know you said there were a few things. Could you go into that a little bit more in depth?

Greg Ness: Sure. The initial treatment in a lot of these cases is an anti-inflammatory medicine, think Advil or its cousins. Resting your jaw. You know, think what you might do, for example, for a sprained ankle. You can walk around the house, but you can’t go play soccer or it will never get better. So, the jaw equivalent is not biting and chewing food, and that gives the joint an opportunity to rest, heal, and that can be really helpful for jaw muscle ailments as well. Sometimes you go onto to use a bite splint, plastic devices you wear on your teeth that are really like the orthotics that you would wear for other joints or receive formal physical therapy. And in some cases, stress plays a role in these things and recognizing that role in managing your stress becomes a part of the solution as well.

Host: And then again, so if what you talked about there, the splinter bite plate therapy or stress management and those other first-line treatments, if they don’t work, that’s when you decide, “Okay, we might need surgical intervention.”

Greg Ness: Right. There are really two parts to that decision. One is, have you tried the appropriate non-surgical treatment? And two is, are you sure you've really got a problem in the joint? Because there is no operation that's going to treat muscle problems, neurological problems, or other things that can mimic joint problems. Then, if you're sure you have a problem in a joint that you can treat with an operation. There are several things that we can do.

Sort of increasing complexity or invasiveness. We start often with a procedure called arthrocentesis, which is a big word, but what it really means is we rinse the joint out. We flush sterile fluid through the joint and wash it. That's a fairly simple office-based procedure. It's on the medical scale of things. It's a low cost, low risk procedure, and it can be highly effective for inflammatory problems in the joint.

The next step might be something like arthroscopy. As we've mentioned before, this is where you're doing much of the same kind of thing, but now you're using a scope, a tiny telescope-like instrument to look in the joint. When those things aren't going to be effective, most surgeons would turn to an open operation where you actually make an incision into the joint itself, and then you can repair or remove damaged tissue, you may reshape the bone and remove bony abnormalities. That's another whole grab bag of different things you might do inside the joint once you're there.

And then, probably the most invasive or most complex situations require replacement of the joint. And that's done with a couple of things. You can either borrow bone from somewhere else in the body. A rib for example is commonly used, or we have some excellent FDA-approved artificial joints that can be used to reconstruct the TMJ completely.

Host: So, you would use a bone graft then to reconstruct that jaw?

Greg Ness: You might. Although, honestly, that's not done as commonly now as it was even a decade or two ago, because we've gained so much experience with the artificial joints and it really has some great state-of-the-art technology to work with in that arena.

Host: So, when it comes to surgery in general, I know there’s a bunch of different variables. What is surgery like? How long is the recovery? What would a patient expect?

Greg Ness: Yeah, that’s a great question. And it’s really variable. For an arthrocentesis, for example, where you’re just rinsing the joint in the office, most people are stiff and sore a little bit for a day or two, and then their joint starts really feeling a lot better. If you have a major jaw surgery or joint reconstruction surgery, that can be a week or 10 days at home recovering and maybe even a little longer period before you enjoy chewing food again.

Host: Right. Yeah, that makes sense. This might be a goofy question, is there a way to minimize risk of TMJ? Are there things we can do to stop the onset of this?

Greg Ness: You know, no, that’s actually a great question. I wish I knew the answer, because I could be, you know, really famous. We don’t know what kicks off the problems. For example, as I mentioned, it’s very common to have that disc in the joint get displaced. We don’t know why most people do really well with that. The joint adapts, and they might hear some popping or clicking, but there’s no pain or dysfunction. And other people do really poorly with that and have a lot of pain and limited movement and require ultimately an operation to treat it.

Host: Hereditary, does that play any role in this at all? Again, I’m just asking to ask.

Greg Ness: Not that we know of, although there’s a lot of interesting research going on looking at all the things that might go into this problem, including things like genetic predisposition.

Host: Well, it seems like it would make sense at least to look at that and see if there is a relationship there between the two. So, when it comes to TMJ, how can an OMS help with this?

Greg Ness: Well, when you have symptoms of TMJ trouble, most people will see their primary care doctor or their dentist. And this would be a great opportunity for you to ask for a referral to an oral and maxillofacial surgeon. Oral surgery is a specialty that really emphasizes treatment of all the diseases in the areas of the mouth, teeth and jaws, and an oral and maxillofacial surgeon is in a good position to diagnose these problems. That's really important because the cause is a critical guide to the treatment. And in some cases, that might be a diagnostic process that's based mostly on the history that you bring with you and your description of the problem. But in some cases, specialized imaging might be necessary or referral to other dental or medical specialists or a physical therapist might be a part of the workup.

Host: Right. But an OMS would be an expert in dealing with certainly TMJ. And if you do have to have the higher, more intense level of treatment, of course.

Greg Ness: Absolutely. I think this is a core part of the training in oral and maxillofacial surgery. And I think that's unique among all medical and dental disciplines.

Host: Well, it's good to know this, and that's one of the great reasons we do these podcasts. As you said, it generally would start out with someone's primary physician and then a dentist, but really an OMS is specifically trained in these areas.

Greg Ness: Absolutely.

Host: Yeah. Dr. Ness, let me ask you about this. Does Botox play a part in TMJ disorder treatment at all?

Greg Ness: That's a great question. Strictly speaking, Botox itself is a medicine that relaxes muscles. And so, it doesn't really play a role in treating joint disease. But Botox can be a very useful thing for people who have painful, stiff jaw muscles just as it's used in other parts of the body. That used to be a kind of controversial, fringy treatment, but there's some good evidence now that it could be very useful, particularly for patients where other lines of treatment have not worked well.

Host: So, Botox will generally wear off after time. Is that the case with TMJ when using it to treat TMJ? Will, in time, it potentially would wear off to, "I am having the problem again?"

Greg Ness: That can happen. If you look at the science on Botox in jaw muscles, much like in other parts, it's something that often has to be repeated in three or four months.

Host: Okay. Got it. That makes sense. So, I just wanted to ask about that to understand the relationship between Botox and potential treatment for TMJ. So, thank you for that. Is there anything else you want to add as we wrap up, Dr. Ness?

Greg Ness: I think I'd say a couple things to people who might be concerned about whether they have a TMJ problem. One is, if you have some concern, don't delay. Get yourself in to your primary care doctor, your dentist or see an oral and maxillofacial surgeon, which would be a great opportunity for a referral to an expert in this particular area. But at the same time, don't despair. The vast majority of these problems really do take care of themselves with time or with minimally invasive short-term treatment, they don't turn into big long-term problems for most people.

Host: Anything you want to add as we talk about TMJ disorders surgical versus non-surgical treatments?

Greg Ness: I think the one thing I might say is that for people who have early problems, a little pain, with popping and clicking, don't get too alarmed because in most cases, these are things that can be treated by simple measures and they get better and time is probably on your side.

Host: That's very well said, and ending on a positive note. I love it, Dr. Ness. That's why we love you. So, thank you so much for your time. This has really been informative. Thank you again.

Greg Ness: You're very welcome. Enjoyed it.

Host: Yeah, absolutely. For more information and the full podcast library, please visit MyOMS.org. And if you found the show to be interesting, please share it on your social media and don't forget to subscribe. Thanks for listening.