TMJ Pain; the Interesting Case of Richard B

Dr. Halligan
Dr. Halligan

Richard B. was referred to my office for an evaluation of his TMJ and facial pain. The pain was only on his right side and it affected his jaw joint and the facial muscles—masseters and temporalis. And the odd thing was that the pain was worst when Richard chewed on the left side. In fact, chewing anything at all on the left side could trigger right side pain that lasted for hours.

Obviously, Richard had learned not to chew on the left. Even so, he often woke up with moderate to severe jaw pain on the right and it would persist throughout much of the day.

Richard was referred by one of the better dentists in town and someone who had already looked for anything obvious, including wear facets that might indicate bruxism. He saw nothing obvious.

At the intake interview, Richard stated that the pain had started a few months before and that he couldn’t think of anything that might have caused it; he simply woke up one morning with right side pain and it had persisted every day since.

Richard never had orthodontics but did have his left side wisdom teeth removed. His right 3rd molars were still present.

Richard had normal range of motion, that is good opening with minimal to no pain, normal joint sounds or vibrations, and imaging showed normal condyle-glenoid fossae architecture.

T-scan showed close to normal tooth contact when Richard closed on his back teeth–notice though that his left 3rd molars had harder than ideal occlusion (C.O; or MIP). Right side chewing showed good canine guidance with only minor posterior interferences.

But what about left side chewing? Thanks to T-scan—although frankly it could have been discovered without that technology—the problem was instantly clear. Whenever Richard moved his lower jaw to the left, as one would obviously do when chewing on the left, the hardest tooth contact by far was on the right side wisdom teeth.

Patient’s normal closure. Hardest teeth hitting? Right side wisdom teeth.
Patient’s normal closure. Hardest teeth hitting? Right side wisdom teeth.

 

On right lateral excursion good canine guidance but with minor working side intereferences.
On right lateral excursion good canine guidance but with minor working side intereferences.

 

On left lateral movement heavy contact on the right 3rd molars.
On left lateral movement heavy contact on the right 3rd molars.

 

Bar graph of left lateral excursion showing that extreme contact on the right molars.
Bar graph of left lateral excursion showing that extreme contact on the right molars.

 

How would one find this without expensive computer hardware and software? I placed articulation paper over the right side teeth and said to Richard, “This may be a little confusing because I’ve got this marking paper on the right side of your mouth. I want you to ignore that and pretend you’re chewing something on the left. So grind on your left back teeth a few times.”

Richard did so. By the way, as a dentist you have to watch carefully because despite that instruction many folks will just grind on the paper. You have to observe which way your patient’s mandible moves. Richard did it correctly. And there, on the lower right 3rd molar was the very obvious big blue mark showing where the lingual cusp of the upper molar was banging away on the lingual slope of the buccal cusp of the lower molar. And then, wiping away the blue ink with a 2X2 gauze square, I could see the rather clear shiny worn area on that lower 3rd molar.

So that was the problem and it was easily solved with a little diamond in a hand piece to adjust that area.

It’s interesting to ponder what steps might have been tried for Richard. Extracting the right wisdom teeth? Sure. Night guard? Of course. That’s often the first step, and done properly might have even helped with morning pain. Pain would have likely returned with the first few bites of breakfast however.

Pain medications? Certainly.

Daytime and night time splints or orthotics? Yes; and again that might have even helped. But in the absence of an actual TMJ problem, not the right course of action in my opinion.

One of the giants of dentistry, the late Peter K. Thomas, once told me—as he probably told hundreds of young dentists: “The dentist should know the tops of the teeth the way Rubenstein knows the keyboard of the piano.”

I hate to admit it, but at the time, nearly 50 years ago, I thought he was exaggerating. He wasn’t. In my work I concentrate on the architecure of the temporomandibular joints. But sometimes, in fact often times, there is an easily observable problem with the way the “tops of the teeth” connect with each other, and no actual joint pathology.

There is plenty of evidence (in particular see articles by Dr. Robert Kerstein) that posterior tooth contact upon lateral movement will cause painful muscle contraction.

The trick is to observe those interferences.

And notice that I said, ‘easily observable.’ That doesn’t always mean easily fixed. Although for Richard I doubt it took much more than 30 seconds.

T-scan allowed me to see Richard’s occlusal interference clearly and in an instant.

According to the T-scan people, only about 1.0% of dentists are using this technology. I actually think that’s a shame. You were amazed by what you’d been missing when you first started using magnification? Be prepared for the same kind of eye-opening experience: you’ll be able to see your patient’s actual occlusion in real time displayed on a screen right before your eyes. Is that new crown high? Or is it not quite in occlusion? How does it function when your patient moves into lateral excursions. You’ll know the answer quickly and with great accuracy. Good old articulation paper still works of course, but T-scan puts you miles ahead. It’s worth a look.

Disclaimer: I have no financial interest in T-scan nor am I compensated by them in any way.

 

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