Clenching & Grinding



What Is bruxism?

Bruxism is the technical term for grinding and clenching that abrades teeth and may cause facial pain. People who grind and clench, called bruxers, unintentionally bite down too hard at inappropriate times, such as in their sleep. In addition to grinding teeth, bruxers also may bite their fingernails, pencils and chew the inside of their cheek. People usually aren't diagnosed with bruxism until it is too late because so many people don't realize they have the habit. Others mistakenly believe that their teeth must touch at all times. About one in three people suffer from bruxism, which can easily be treated by a dentist.

Just because you're old enough to know better, doesn't mean you will not pick up bad habits. Bruxism is a common, and usually unrecognized nightly routine that often develops in adults, according to the Academy of General Dentistry, an organization of general dentists dedicated to continuing education.  Bruxing is the involuntary gnashing or grinding of teeth. It's frequently done unconsciously while sleeping, and is often associated with emotional stress. A common characteristic among bruxers is the tendency to deny doing it. Recent studies show that grinding can lead to crumbling teeth, chronic headaches and constant jaw pain. The challenge for both dentists and patients is to get bruxers to recognize the habit before irreversible damage occurs. Despite showing many symptoms, such as awakening with tired jaws and headaches, or flattened teeth and tooth pain, many patients say "I would never do that," People should realize that bruxism is often simply a reaction to stress; some people get an ulcer and others grind their teeth,

A spouse or significant other can play a key role in helping bruxers get the treatment they need. If your spouse complains about strange, squeaking noises that keep him or her awake at night, you may be grinding your teeth.

Grinding your teeth can be very damaging to the teeth and also difficult to stop. If vigorous grinding occurs at night, teeth can be worn down to the gumline because the instinctive reflex to stop does not work while you are sleeping. Grinding due to stress can only be cured by removing the stress trigger.  

After overcoming the denial phase, treatment is fairly straightforward. Your dentist may prescribe a molded plastic mouth guard that absorbs the stress of grinding during sleep. And while the mouth guard won't prevent you from grinding, it will prevent damage to your teeth, jaw joint, and relieve the extra stress to your face.

Can bruxism cause harm?

People who have otherwise healthy teeth and gums can clench so often and so hard that over time their teeth

become sensitive. They experience jaw pain, tense muscles and headaches along with excessive wear on their teeth.

Forceful biting when not eating may cause the jaw to move out of proper balance.

What are the signs?

When a person has bruxism, the tips of the teeth look flat. Teeth are worn down so much that the enamel is rubbed off, exposing the inside of the tooth which is called dentin. When exposed, dentin may become sensitive. Bruxers may experience pain in their temporomandibular joint (TMJ)-the jaw-which may manifest itself as popping and clicking. Women have a higher prevalence of bruxism possibly because they are more likely to experience tissue alterations in the jaw resulting from clenching and grinding. Tongue indentations are another sign of clenching.  Stress and certain personality types are at the root of bruxism. For as long as humankind has existed, bruxism has affected people with nervous tension. Anger, pain and frustration can trigger bruxing. People who are aggressive, competitive and hurried also may be at a greater risk for bruxism.

What can be done about it?

During regular dental visits, the dentist automatically checks for physical signs of bruxism. If the dentist or patient notices signs of bruxism, the condition may be observed over several visits to be sure of the problem before recommending and starting therapy.

The objective of therapy is to get the bruxer to change behavior by learning how to rest the tongue, teeth and lips properly. When some people become aware of their problem, simply advising them to rest their tongue upward with teeth apart and lips shut may be enough to change their behavior and relieve discomfort. However, the dentist can make a plastic mouth appliance, such as a night guard that's worn to absorb the force of biting. This appliance can prevent future damage to the teeth and helps change the patient's destructive behavior.

Biofeedback is used to treat daytime clenchers by using electronic instruments to measure muscle activity and to teach patients how to reduce muscle activity when the biting force becomes too great. Researchers are looking for other ways of treating bruxism, especially for those who tend to clench in their sleep. One researcher developed an experimental lip simulator that electrically stimulates the lip when a person bites down too hard while sleeping. However, that method is being refined because the stimulation can wake sleepers several times in a night.

Understanding orofacial pain and temporomandibular (TMJ


A temporomandibular disorder (TMD), often incorrectly referred to as "'TMJ”, involves more than a single symptom. The facial muscles (chewing muscles located on either side of the face), the jaw joint itself, the ligaments attached to the joint, and other associated structures may all be involved with this problem. About 75% of the North American population have experienced, at some time, joint tenderness, joint noise, or temporary jaw locking. Signs and symptoms of temporomandibular disorder commonly appear when people are in their 20s, although teenagers frequently report joint clicking sounds.  The most common symptom is pain in front of the ear, over the Jaw joint, and in the face muscles. The discomfort may involve one or both sides. You may also experience earache, headache, and face pain.

The pain may come on suddenly, or the symptoms may develop over a prolonged time with your distress gradually increasing in severity. You may find that your problem becomes long lasting, or chronic.  It is important to understand that the chronic nature of the pain and the jaw problem may require a prolonged treatment period, which may include physical therapy, medication, short term use of removable dental appliances worn over the teeth, and other types of care that will be discussed later. Dentists usually devise treatment programs that are as conservative as possible, with more involved or extended procedures added only if results are not favorable. If the treatment selected for your condition does not help you, or if your distress increases, further diagnostic studies and evaluation will be necessary. This may include consultations with your personal physician, or with dentists or physicians who specialize in treating diseases or disorders associated with muscles, bones, or neurological and psychological conditions.


The Temporomandibular Joint

The temporomandibular joint (TMJ) is a sliding and rotating ball and socket joint located just in front of the ear. It consists of the temporal bone (side and base of the skull) and the mandible (lower jaw), hence the name temporomandibular joint. A fibrous disc called the articular disc is positioned between the temporal bone and the mandible. This disc acts as a cushion between the temporal bone and the mandible. By placing the tip of your index finger directly in front of your ear and opening and closing your mouth, you can feel the tip of the lower jaw bone, the condyle (from the Greek word for knuckle), move in and out of the fossa, or socket. You may also feel the movement of the disc or hear a clicking sound as the jaw opens and closes.


Temporomandibular disorder (TMD) is a term used to describe a number of problems that involve the jaw muscles and/or temporomandibular joints. There are numerous symptoms, which may fall into one of the following patterns:

* Symptoms occur on one or both sides of the face and, at times, may cause or be related to pain in other areas of the face, head, and jaws

* Symptoms develop soon after an injury to the face or jaws

* Symptoms develop gradually in association with related medical problems

* Symptoms develop with an increase in habitual muscle overuse and/or stress levels

The lower jaw (mandible) and its joint is a unique body mechanism. Unlike the hips, shoulders, or knees/ which can function individually, lower jaw function requires that both right and left joints be synchronized during their movement. In proper jaw function, the right and left jaw joints move as one unit; they are twin structures. If, for some reason, this simultaneous movement is upset, the jaw may turn or twist during its opening, closing, or side motion movements. Of course, the muscles that control TMJ movement have to be healthy and functioning normally for coordinated jaw movement. However, for those patients who have TMD, the muscles are almost always injured in some way, which may be why the right and left jaw joints lose their movement harmony. This abnormal joint movement behavior or loss of coordinated jaw movement can produce problems with the protective discs and the joints.

The following symptoms are characteristic of TMD.

Jaw pain

A common symptom is pain in and around the jaw joint. This pain is usually felt while you are opening and closing your jaw, but can occur while you are resting your jaw. The pain is characterized as a fairly prolonged, deep, dull ache, often similar to the discomfort associated with a nagging headache. Sharp, brief, shooting pain or a feeling of numbness in the face requires additional medical or neurological consultations.


Many TMDs produce headaches of varying severity as symptoms. Jaw muscle contraction is often associated with long term headache, and may cause pain in muscles during chewing, speaking, and swallowing. TMDs often contribute to or aggravate a preexisting headache that is not of temporomandibular origin. On the other hand, the discomfort and stress associated with a migraine or vascular headache can cause tightness in the muscles that control:jaw movement, and may extend to the muscles of the neck and shoulders.

Jaw Noise

Patients with TMI)s often hear clicking, popping, or grating noises in their temporomandibular joints. The articular disc, which is positioned between your condyle and temporal bone (see page 5), normally acts as a "'shock absorber." The clicking noise commonly heard and felt during mouth opening or closing is a result of this disc slipping out of place, sticking, or malfunctioning. It is reassuring to know that clicking and popping sounds in the jaw joint are quite common and seldom significant. However, when the sound is grating or gravellike, the joint and disc may be breaking down (degenerating), and this requires a more involved investigation. Clicking sounds may occur in one or both joints when the bony joint and disc movement are not coordinated. The click may occur when you open your jaw or during closing and lateral movements as well. Your jaw may shift to the side and may catch or lock during any of its movements.

Difficulty Opening and Closing the jaw

Normally, the TMJ (condyle and disc) opens and moves forward or sideways smoothly, quietly, and without pain. However, following some form of injury, pressure, or degenerative process, the moving joint parts become worn. The disc may begin to catch, stick, or become displaced, thus limiting the range of jaw motion. This is called TMJ internal derangement. There is a progressive sequence of stages in this internal derangement process. The disc can slip forward and temporarily be caught or trapped, resulting in a click and momentary locking of the jaw. However, the disc quickly reorients itself and normal jaw function is restored. Sometimes this problem can worsen. The disc wear can continue and result in a more severe displacement.

Some individuals develop a hyper-mobility or overextension of their jaw joint during mouth opening. This results in the condyle opening beyond the limits of the joint socket. Occasionally, this can be a painful event that results in a reflex contraction of the chewing muscles, which lock the jaw in an open dislocated position. This is referred to as an open lock. There are some people who learn how to gently relax and massage their jaw and face muscles. This permits the jaw joint to slip back into its proper position. Those individuals who experience this event with some frequency learn to avoid activities like wide yawning, and they modify eating certain foods, such as apples and large sandwiches, by cutting them into small pieces.

If the jaw will not return to its normal position, it is necessary to go to an emergency room or immediately to your dentist’s office where the jaw can be repositioned without too much difficulty. The emergency room staff or your dentist may use medications that will produce muscle relaxation, possibly including local anesthesia or intravenous sedation. Single occurrences of jaw locking are usually not worrisome, but repeated disc dislocation with frequent locking requires treatment. Such treatment is usually non-surgical, but unresponsive cases may require surgical disc repair or removal.

Chewing and Biting Difficulty

A common symptom of TMD is pain when chewing and biting. There is also restricted, uncomfortable jaw opening during eating, yawning, and other activities. While you are being treated for face pain or a TMD, your dentist will advise you not to chew gum, lettuce, nuts, firm meat, caramels, and substances of similar consistency. If your treatment is successful, you should be able to gradually return to chewing foods of your choice. If your TMD has not been too severe or complicated, firm foods, such as those identified here, do not have to be avoided beyond the treatment or recovery period.


Most of the reasons why your jaw and face hurt are not life threatening, but the pain can be extremely distressing. It is important to be aware of all the various factors that may contribute to the development of TMD.


Grinding and clenching of the jaws commonly occurs during sleep, but can happen at any time, day or night; this habit is called bruxism.  If you clench or grind your teeth during sleep, you can experience jaw and face muscle fatigue and soreness and awaken with pain on both sides of your face and head.  Because some types of bruxism are habitual, you may not be aware of its presence. Your dentist may find excessive wear patterns on the surfaces of your teeth and ask if you are aware of a tooth grinding habit. Bruxism is commonly associated with stress and anxiety. Bruxism may also be related to some medications, particularly major tranquilizers, alcohol, and some illegal drugs.

A bruxism problem can become quite serious for some individuals and cause severe mobility or loosening of the teeth and discomfort in the jaw joint and face muscles. The noise associated with grinding that occurs during sleep can become extremely annoying to a bed partner or roommate. Your dentist may be able to help you reduce bruxism through the use of appliances or behavior modification techniques, which will be described later. If his or her efforts do not result in adequate relief, then a more extensive behavior modification therapy may be recommended. Such therapy is usually done by a clinical psychologist and can be helpful not only in resolving the bruxism but in identifying some other previously unrecognized stress patterns.

Bite or Occlusal Alterations

The terms bite and occlusion describe the relationship of the upper and lower teeth when the jaws are in a closed position. The involvement of the bite or occlusion as a causative factor in TMD is not well understood and is not considered to be a primary factor for most patients. Your dentist may determine, however, that malocclusion (poorly aligned teeth) is one factor among several that aggravates or contributes to the development of TMD.


Injury to the muscles that permit the jaw and the joint to function is a major cause of TMD. Some of these injuries include those from sports, a violent blow to the face and/or jaws (as in some kinds of automobile accidents), and biting on hard food or on an unexpected hard particle (eg, cherry pit, popcorn kernel), to name just a few. These injuries may prevent your TMJ from operating properly, resulting in the symptoms listed above.

Stress and Anxiety

Muscle tension associated with stressful everyday life events or lifestyle changes may cause the development of a TMD. The anxious patient may overuse their jaw muscles by clenching, grinding, or gnashing of teeth (bruxism). Often, muscle soreness occurs when a jaw or facial muscle is overused or overstretched. Another side effect of excessive jaw muscle contraction (tightness) is headache. The patient who is experiencing pain in these over stressed jaw muscles will try to favor or compensate their jaw movements. This produces a disharmony in the jaw function that not only increases the muscle discomfort but also interferes with normal TMJ motion. A vicious circle of stress, muscle tightness, and joint limitation is created, sometimes resulting in associated pain.


Several of the forms of arthritis that develop in other bony joints may also be found in the TMJ. The most common is osteoarthritis, which occurs as we age, although it can develop earlier due to an injury to the jaw joint. Arthritis can cause the degeneration of the bone in the TMJ and erosion of the condyle, which can lead to TMD.

There is no evidence that clicking of the joint indicates the presence of arthritis or that if clicking is untreated it eventually results in arthritis. On the other hand, as mentioned earlier, the grating or rough sound in a joint during movement may be an indication that arthritic changes are present. This latter condition may require a cooperative study and management by both dentist and physician.

Perhaps you recently had a lengthy dental appointment and kept your mouth open and fully stretched for a long time. You may find that your jaw muscles feel sore or stiff after such a long session. This discomfort usually disappears within a day or so. It stems from an over stretching and/or prolonged unmoving contraction of the jaw muscles or joint tissues. It is not a result of improper dental therapy.

Lengthy Dental Procedures

When a general anesthetic has been necessary for a surgical procedure (including some outpatient surgery), the mouth is opened as wide as necessary to permit the anestheseologist or anesthetist to insert a tube and maintain an open airway. Sometimes the jaw must remain in this wide open position for a lengthy period, resulting in considerable postoperative discomfort.  This type of discomfort and pain does not necessarily signal the presence of a TMJ, and the pain may disappear on its own or with relaxation of the jaw muscles. If they do not, however, an examination for signs of TMD is indicated.

Other Factors

There are other conditions that may contribute to TMD Neurologic disorders such as parkinsonism, myasthenia gravis, strokes, amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease), and a number of others may cause uncontrolled excessive jaw movement, as well as a generalized body muscle movement disorder. The misuse and abuse of drugs can also contribute to abnormal jaw function. Some drugs are known to damage that part of the nervous system that controls coordinated muscle movement, which may result in face injury to the TMJ.


Most of the symptoms of TMD are associated with varying levels of pain. Pain is a highly personal, emotional response to stress or injury to tissue. There are two types of pain, acute pain and chronic pain; their characteristics are listed below.

Acute Pain- Useful pain (alerts you), Short duration, Obvious signs and symptoms, Treatment is effective, Causes no disability

Chronic Pain- No useful purpose for pain, Prolonged duration, Unclear signs and symptoms, Treatment can be ineffective, Frequently causes disability

Both types of pain are associated with TMD, although the presence of one or both types does not necessarily mean that you have TMD. The intensity, duration, and responsiveness to treatment of pain vary with each individual.

Myo-fascial Pain Dysfunction Syndrome

This is a common type of muscle aching and can occur in any part of a single muscle, tendon, or ligament, or in groups of muscles (myo = muscle., fascia = fibrous connective tissues that cover the muscles). Dentists will sometimes refer to the combination of sore muscles of the face and jaws, joint clicking, and limitation of motion as myofascial pain dysfunction syndrome.

Myofascial pain may be a generalized condition occurring in other parts of the body. It can occur in the back, shoulders, neck, or jaw muscles. Sometimes myofascial pain is used as a substitute term for other conditions that produce muscle ache, such as fibromyalgia, fibrositis, tension myalgia, lumbago, stiff neck, or tension type headache. These terms are all somewhat confusing and not easily defined, but by and large, myofascial pain is more of a muscle ache than muscle pain. If you have generalized myofascial pain, your muscles may ache more and feel tight or stiff in the morning on awakening. People with myofascial pain often sleep poorly and feel fatigued on awakening in the morning. Physical and emotional stress also increases this discomfort.

If you are able to locate and touch a specific spot of pain in a muscle, such as in the face muscle, that tender spot is called a trigger point. These are tender sites from which pain spreads out over a larger area. Your dentist or physician may locate this trigger point or isolated tender region and use a coolant spray, ice, or in some instances inject a small amount of local anesthetic directly into the painful spot. These treatments plus physical therapy may give you considerable relief. Myofascial pain can also be relieved with aspirin or aspirin-like drugs (commonly referred to as anti-inflammatory agents) and/or muscle relaxants.

Muscle Overuse Activities

Most of the previously mentioned muscle overuse activities, including bruxism, biting on hard food, muscle tension, muscle spasms, and muscle splinting, may cause pain in muscles during chewing, speaking, and swallowing. The presence of pain, however, does not necessarily mean that these activities have caused TMD. A thorough dental and medical examination is necessary to determine if the pain is a sign of TMD.



To determine whether you have TMD or another disorder, a dentist may first ask you a series of questions, such as:

* Do you have pain when you chew or yawn?

* Do you hear a noise in your jaw joints?

* Does your jaw lock or get stuck when you talk, yawn, or eat?

* Does your bite feel different?

* Have you had an injury to your jaws, neck, or head?

Have you ever had previous diagnosis of or treatment for this problem? If so, what type of treatment and result?


To determine the physical characteristics of your jaw, a dentist will:

* Measure the range of opening, lateral, and forward movement of your lower jaw

* Identify the type of noise your TMJ makes

* Evaluate the function and discomfort of the muscles of your jaws, face, and neck

* Evaluate the condition of your teeth and bite or occlusion (how your teeth come together when you close)

* Check the symmetry of your face and jaws

Diagnostic Aids

The dentist may do tests and studies to gather more information about your condition. These may include:

* Radiographs (xrays) of the temporomandibular joints.

* Specialized tests (if necessary) to rule out other causes of disease; these tests may include biopsy (removal of tissue for microscopic study), magnetic resonance imaging (MRI) for soft tissue injury, blood chemistry studies, and plaster casts or models of your teeth.


Once your dentist has determined that you are suffering from TMD, your dentist will review the treatment options with you.

There are a number of treatment options and a variety of terms used to describe these different methods of treatment. However, most of the care your dentist will provide will include at least two or more of the following:

* Patient education and self care

* Behavior modification, including stress management and relaxation techniques

* Medications

* Physical therapy

* Orthopedic appliance therapy (orthotics)

* Occlusal (bite) therapy; rarely required

* Surgery

* Pain management center referral

Above all, the objectives of any treatment are to:

* Reduce your pain

* Restore comfortable function to your jaw

* Limit recurrence of the pain

* Supervise a program of education and self care

* Restore normal life patterns as much as possible

As noted earlier, every treatment program begins with a thorough discussion between you and your dentist or physician to define, describe, and clarify the characteristics of your disorder. The symptom extent of the disorder, and reaction and perception o pain are highly individualized. It is important that you and your dentist discuss

the various treatment options, the rationale for their use, outcome expectations, and the need and type of followup care that both you and your dentist must follow.

Behavior Modification (Stress Management and Relaxation Techniques)

Stress factors play a major role in TMD. Habits such as tooth grinding, jaw clenching, or excessive jaw movement may be associated with underlying stress. Many people are unaware of other habit patterns that involve the teeth and jaws, such as chewing on the end of a pencil or cradling a telephone during lengthy conversations, or work related patterns that involve stressful use of the jaw, face, or neck muscles. Not all of these habit patterns result in significant or symptomatic TMD. Many people are able to control or stop these habits when they are made aware of them.

However, if a habit persists and results in injury to and discomfort in the jaw and facial muscles, a specifically structured treatment program of behavior modification should be considered. Some of the treatment methods used in the care of chronic pain and many behavior modification techniques, such as the use of relaxation tapes and self awareness programs, are found to be more effective when they become part of a more intense form of therapy called biofeedback.

Biofeedback is a learned technique generally directed by trained specialists, often psychologists. Biofeedback therapists have developed their clinical skills through advanced and graduate work in the care of the distressed or depressed patient. These therapists are highly specialized and must be certified in order to practice and administer this care to patients.

Biofeedback assists you in understanding and learning how your body reacts to excessive or harmful stressful experiences. As a pretreatment study, the biofeedback therapist places light surface contacting electrodes over your facial, head, and neck muscles to measure the amount of muscle activity during various levels of jaw movement. These recordings often demonstrate hyperactivity (too much activity) in muscles that appear to the eye to be in a quiet state. The therapist then uses these recordings to monitor treatment progress. As you continue to use the relaxation techniques taught by the biofeedback therapist, you can observe the favorable reduction of muscle activity visible on the electronic recording device; thus you can see your own ability to reduce the muscle hyperactivity that causes your distress. As you improve, the muscle function gradually returns to a more normal, less painful state.


The use of medications to relieve pain, inflammation, anxiety, depression, and muscle soreness is an effective part of a carefully managed rehabilitation program. Medications provide an essential supplement to the care of the patient with acute or chronic pain and/or jaw problems.

There is no single drug that will relieve all signs and symptoms of TMD; however, a series of physical therapy treatments plus anti-inflammatory agents, such as aspirin or ibuprofen, taken as directed will relieve discomfort and restore function.

Your dentist or physician may also prescribe muscle relaxants or antidepressants (for chronic pain, not necessarily for depression). These are for short-term use, to be taken only while you are under the continuing care and supervision of your dentist or physician.

People who suffer with long-term pain must be particularly cautious to avoid drug misuse or abuse. If you are under the care of several physicians, be certain that they know the number and type of medications that you may be taking, as there is the possibility of over-treatment or overmedication. Both you and your dentist or physician must carefully monitor medication use and effectiveness.

There are numerous medications used for treating arthritis. While some family dentists and physicians are generally knowledgeable in diagnosing and managing people with an arthritic jaw joint, if there is a generalized systemic arthritic condition, the most help in diagnosis and therapy would come from a specialist in rheumatology. This is particularly important because the arthritis identified in a TMJ is likely to exist in other joints. Treatment prescribed by a rheumatologist or physician can be expected to relieve similar symptoms of the jaw joint. Your dentist may, however, supplement that treatment with physical therapy and/or appliance therapy, which uses a device designed and fabricated to help stabilize the jaw joint, the bite, and reduce jaw joint and face muscle discomfort.

Physical Therapy

Many people develop TMD symptoms that are similar to the sprains or injuries that occur in the ankle " knee, or shoulder. Because TMD involves muscles, ligaments, tendons, and bony structures, your dentist or physician may prescribe physical therapy. This treatment is designed to relieve discomfort and restore function by reducing inflammation (swelling), strengthening the muscles, and permit healing of injured structures. Your physician or dentist may also instruct you on a home care program that involves the use of either cold or hot packs.

Ice packs are usually recommended for use immediately following an injury. Hot moist packs, on the other hand, are used for the continuing longer term, lingering discomfort.

Your home care program may also include posture training for the jaw, head, neck, and instructions for stretching and exercise.  If this modest home physical therapy routine does not help you, your practitioner will likely refer you to a doctor of physical medicine (a physiatrist) or to a registered physical therapist for individualized, specialized treatment.

Orthopedic Appliance Therapy

A plastic device (often referred to as an intraoral splint or orthotic or night guard) fabricated by your dentist that fits over all of your upper or lower teeth is commonly used in the treatment of TMD. This removable acrylic appliance may be worn for a period from a few months up to a year. Different appliances are constructed to address specific causes of TMD.

Among the many advantages that appliances offer you are:

* Relaxed jaw and face muscles

* Reduced discomfort

* Jaw stability

* Reduced clicking or popping noises in your TMJ

* Occasionally a reduction or elimination of jaw clenching or tooth grinding

* Relief of the facial and jaw muscle discomfort that may cause a headache or aggravate a preexisting one

It is important that you practice proper oral hygiene (brushing and flossing) while you are using an appliance. Otherwise, your gum tissues may become inflamed (swell), or dental caries (cavities) or abnormal movement of your teeth may develop. Use of an appliance beyond the recommended treatment period can result in serious and potentially irreversible abnormal shifting of your teeth and bite. However, it is not uncommon for you to feel that your teeth might not "bite right"' when the appliance is removed, but this is a temporary change easily managed by your dentist.

As your distressing symptoms subside, your dentist will reduce the amount of time that you wear the appliance. Your dentist will also schedule you for a number of adjustment appointments during the course of appliance therapy. If you do not show some measure of improvement after using the appliance for a I or 2month period, the diagnosis and treatment should be reevaluated.

Depending on circumstances, most continuous appliance wear does not exceed 6 to 9 months except for persistent bruxism (tooth grinding and/or jaw clenching) during sleep, which may require indefinite wear. Appliances that are intended to reduce or prevent jaw clenching or tooth grinding are usually worn only during sleep. They may be made of either a hard or soft plastic material., Remember that orthopedic appliances are not expected to "'cure"" your problem, but they may reduce the clicking noise and should reduce discomfort and increase range of jaw motion.

Occlusal (Bite) Therapy

Occlusal therapy, restorative, orthodontic, or prosthodontic intervention may sometimes be indicated to correct conditions that are a result of a TMD. In these limited cases, your dentist may choose to reduce or remove teeth that cause bite interferences (occlusal adjustment), replace missing teeth, use braces (orthodontics) to correct mal-aligned teeth, and/or restore teeth with fillings or crowns. These treatment options are used only after your TMD discomfort has been satisfactorily reduced with the previously mentioned treatment procedures.

If your dentist thinks occlusal therapy will be beneficial to your particular circumstances, he or she will explain the rationale and procedures to you in detail. Some minor bite adjustment and restorations may be necessary and may appropriately follow the resolution of the treated disorder. However, this type of dental treatment is usually required more for dental reasons (ie, tooth sensitivity, tooth wear, tooth mobility, improved chewing) than for TMD itself.


When non-surgical treatments have not relieved the symptoms, your dentist may refer you to an oral/ maxillofacial surgeon. Surgery may be the treatment of choice for certain structural problems, including benign or malignant tumors, adhesions associated with an old injury, inflammation, or fractures. The oral/ maxillofacial surgeon will usually request additional x-rays or MRIs before deciding whether surgery is appropriate for you. Temporomandibular surgery has become an effective treatment for some TMDs that do not respond to other therapies.

The decision to perform surgery depends on the degree of disease or injury present within the joint. Before the surgeon proceeds with any of the surgical options, it is first necessary to confirm that you have not responded to the non-surgical procedures, that the x-rays demonstrate structural changes, and that you consent to the surgery after a thorough discussion of the potential complications and the success rate or benefits. Taking all these precautions increases the possibility of a successful outcome.

Pain Management Center Referral

Some patients with TMD have the potential to develop chronic or long lasting distress. For example, you may have some unfortunate injury, disease, or trauma to the jaw joint, for which you consult your dentist, who records your dental history, examines you, secures necessary x-rays and tests, establishes a diagnosis, and starts treatment. Unfortunately, your pain continues despite the treatment or multiple treatments. This prolonged constant aggravation affects your perception and reaction to the pain. If this agony continues for weeks, months, or years, your problem becomes a chronic pain disorder.

Chronic pain disorder (or chronic orofacial pain) is an agonizing, nearly constant pain in the jaws and face that lasts for a long time (more than 6 months) with a certain amount of resulting frustration, anger, and/or depression. Some people can cope with this disorder and go about their business; but for many, the pain is too deeply fixed, the past multiple treatments agonizingly unsuccessful, and the associated costs beyond control. Disability, depression, and other psychological symptoms become overwhelming. There is then the need for a comprehensive treatment approach, which is available at pain management centers.

Treatment in a pain management center usually consists of patient education and self-care, physical therapy, behavior modification, biofeedback, and counseling. Medications are used only sparingly, with emphasis on eliminating dependence on drugs.

The goal of a pain management program is to help a patient deal with the pain and distress more effectively and return to a normal life. If you have experienced this intense distress in your face, jaw, and dental tissues for an extended period, you may need the care and treatment of dental and medical specialists. Pain management programs are designed to alleviate as much pain as possible and help you cope with the pain that may remain.

Pain management centers are well established throughout the country. They are usually staffed by internists, neurologists, psychiatrists, psychologists, physiatrists, dentists, physical therapists, and other healthcare providers. These care units are usually located in either university or larger staffed private medical centers. Some centers function as outpatient clinics, while some function as inpatient units within a hospital; and for some patients, a combination of inpatient and outpatient care is provided.

It is understandable that anyone suffering constant jaw and face pain will grasp on to almost any promise for relief, even if the treatment is bizarre. Unfortunately, if the source of the pain is not identified accurately, well intended treatment will not only fail, it will make the pain worse. It is, therefore, important to seek the care of dentists and physicians who are specialists in treating chronic pain.

Treatment and recovery are slow, but for the afflicted individual who understands and accepts this concept for care, and who patiently embraces the program, the outcome is most rewarding.


While you are being treated for a TMD or orofacial pain, your dentist will advise you not to chew gum, lettuce, nuts, firm meat, caramels, and substances of similar consistency.

If your treatment is successful, you should be able to gradually return to chewing foods of your choice. If your TMJ disorder has not been too severe or complicated, you do not have to avoid the firm foods such as those few identified here beyond the treatment or recovery period. A good rule to follow is, "'If it hurts, don't force it."' Gum chewing is a good example of how difficult it can be for us just to chew slowly and moderately. For some reason, many of us chew too aggressively. Eat the foods you enjoy and for which there are no personal medical or physical restrictions. just take it easy. Remember, once a jaw joint is injured, it is easily re injured. You should always take care in selecting your foods and chew them carefully. You need to protect your jaw joint just as you would protect a previously injured back, knee, or ankle. To overuse or stress the injured joint can result in a recurrence of your discomfort and cause irreversible degeneration (breakdown).

The pain associated with the TMD should decrease as you progress in your treatment program. TMD is often a chronic condition, which means that it may come and go over a long period. Whenever recurrence threatens, early response is important; return to your home program routine, or if that is not sufficient, seek further consultation and treatment with your dentist. Another period of remission or, it is hoped, permanent resolution will result.


The information presented here, in no way answers all questions, because each person's experiences, symptoms, diagnosis, and treatment are specific. Ultimately, case management is the responsibility of the attending dentist or physician who is personally available to address the patient's distress and provide or arrange for the necessary followup and care.