James E. Metz, D.D.S. 1271 East Broad Street
Columbus, OH 43205
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TMD (temporomandibular joint) disorders are a family of problems related to your complex jaw joint. If you have had symptoms like pain or a "clicking" sound, you'll be glad to know that these problems are more easily diagnosed and treated than they were in the past. Since some types of TMD problems can lead to more serious conditions, early detection and treatment are important.

No one treatment can resolve TMD disorders completely and treatment takes time to be effective. Dr. Metz can help you have a healthier and more comfortable jaw.


Trouble with your jaw?

TMD disorders develop for many reasons. You might clench or grind your teeth, which tightens your jaw muscles and stresses your TM joint. Or, you may also have a damaged jaw joint due to injury or disease. Whatever the cause, the results may include a misaligned bite, pain, clicking or grating noises when you open your mouth, or trouble opening your mouth wide.


Do you have a TMD disorder?

  • Are you aware of grinding or clenching your teeth?

  • Do you wake up with sore, stiff muscles around your jaws?

  • Do you have frequent headaches or neck aches?

  • Does the pain get worse when you clench your teeth?

  • Does stress make your clenching and pain worse?

  • Does your jaw click, pop, grate, catch, or lock when you open your mouth?

  • Is it difficult or painful to open your mouth, eat or yawn?

  • Have you ever injured your neck, head or jaws?

  • Have you had problems (such as arthritis) with other joints?

  • Do you have teeth that no longer touch when you bite?

  • Do your teeth meet differently from time to time?

  • Is it hard to use your front teeth to bite or tear food?

  • Are your teeth sensitive, loose, broken or worn?

The more times you answered "yes," the more likely it is that you have a TMD disorder. Understanding TMD disorders will also help you understand how they're treated.


A more detailed explanation

What is the source of headache pain? Great question!

The purpose of the following test is to differentiate TMD from all other types of head pain, and to give treatment guidelines for the anterior and pivotal appliances.



The jaw and muscles of mastication are two of the many sites in the head and neck region that causes headaches. The term generally used for pain related to the muscles of mastication and the temporomandibular joint is TMD (*). Some other sources of this pain include: Migraines, tension-related headaches, chronic centrally mediated pain, sinus problems, tooth pain, and fibromyalgia.

We all grind our teeth to some degree. This happens most often when people are sleeping, therefore they do not even realize they are grinding (1). The added stress on the system created by the grinding can hurt the joint and cause inflammation of the muscles of mastication (2). Surgery and trauma can also damage the masticatory system producing pain. The pain we feel from the joint is "arthritic" in origin and inflammation of muscles is essentially a cramp.

The goal of differential diagnosis between TMD pain and all other types of head pain is the purpose of this paper.



When the two main  causes of head pain are misdiagnosed or untreated, the sufferer’s quality of life may be significantly altered. TMD is a "basket term" meaning pain in anything connected to the muscles that move the jaw or the jaw joint itself. Migraine is another loosely used term and applied to many pains of known and unknown origin in the head and neck region. Headache as defined by Webster is, "any pain in the head". We must differentiate to have success!

The treatments of TMD and migraine are very different. Using migraine medications to treat TMD can be ineffective to somewhat effective, but the medications can have very serious side effects on some patients. Most migraine medications state that their usage is not effective for relief of TMD symptoms.

It is also ineffective to treat a migraine as though it is TMD. A neurologist can handle the problem of migraine very effectively but not TMD.

The confusion between TMD and migraine arises from the fact that most, if not all, pain information from the head and neck area synapse in only one nucleus of the brain. The message can be "mixed up" in this nucleus, and the cortex "believes" this incorrect information. The anatomic fact of convergence (3), as this mix up is called, gives misleading information to the cortex. An inaccurate perception of pain by the patient is the outcome of convergence (4 ,5). If the doctor relies solely on the patient interview for information, a misdiagnosis may occur, leading to improper treatment. An example of convergence and misinformation is the "ice headache". Cold is in the throat, but where does it hurt?


Stress test to differentiate TMD from other pains

Two Methods can be employed:

   1. Anterior Deprogrammer
   2. Anterior Appliance

The stress test either can confirm TMD as the source of the pain or can rule TMD out of the differential. Stress testing the muscles of mastication, as well as the TMD, will minimize any inconvenience, pain, misery, or cost to the patient.

The test is relatively simple. Testing with the anterior deprogrammer is completed during one office visit. If the Anterior Appliance is used a period of two weeks is required for diagnosis. The Anterior Appliance will be discussed after the Anterior Deprogrammer.

The stress test, utilizing the Anterior Deprogrammer, will stretch the muscles of mastication and put pressure on the temporomandibular joint. If either area is inflamed, the pain produced with pressure duplicates the headache symptom(s) associated with the inflammation. The test begins by placing the patient on the anterior deprogrammer (10 mm. wide and made from sheets of mylar film .1 mm in thickness) and having them bite with "substantial" pressure. The doctor or staff person must sit with the patient, making sure that they stay retruded and continue to bite with substantial pressure. No teeth can touch. However, never ask a patient to continue beyond their endurance. Place warm, moist towels on affected area for comfort. Once pain begins, the patient should alternately bite for six seconds and relax for six seconds. Test must continue for 7-10 minutes. The anterior deprogrammer or similar device is the only method available to stretch the muscles of mastication. Massage cannot give the same result because of the deep anatomic location of the lateral pterygoid muscle. The symptoms created by the test give us the answer to our question. Is it TMD or something else?

The test is simple, but very telling, because of a neurologic principle, primary site stimulation (6, 7) . Primary site stimulation simply means that if you press on an area that is truly causing the pain,  it will hurt more! If you press on an area that is hurting because of referred pain it will not cause or change the pain. If the muscles, which move the jaw and/or the TMD, hurt with the stress test, and the hurt is similar to the "headache" -- we have a diagnosis of TMD. The patient must inform the doctor what they feel -- is it the same as the patient's entire headache or just part of the headache. Many patients are both a TMD and migraine sufferer, with one being more significant. If you are mainly a migraine patient but still have a lesser amount of TMD, treating the TMD successfully will not get rid of the migraine. However, if you are able to eliminate the TMD component, in some situations, the migraine will decrease in either intensity and/or frequency.


Interpretation of test results

One of the following four reactions will occur during the test.

1. Patient only feels tired with no duplication of pain, probably not TMD.

2. Within 60 seconds, it hurts. Generally, the pain is centers in or around the ear (8) . Pain in the first minute is a strong indication of a joint problem (9) .

If there is pain in a displaced joint, than the pain is arthritic. The pain will be more severe when chewing, especially with hard foods. This can be a very “intimidating pain” and is often confused with a migraine. The blue is the pivotal appliance, used for controlling this pain.

3. The pain starts in 3 to 5 minutes. It can radiate into the temples, back of the neck, sinus area, top of head, or just about anywhere else in the head and neck region. The pain will generally cycle (**) and go away within 10 minutes. It is just a cramp, a "Charlie Horse", and it will subside by stretching with the anterior deprogramming device.

Anterior Deprogrammer is inserted. Pain occurs first in joint, which repositions, and then muscle pain or "Charlie Horse". The pain will usually go away with alternately biting on the anterior deprogrammer for 6 seconds and then resting for six seconds.

4. The pain starts out as in number 2 and then changes to number 3 (10) . The joint symptoms will go away with this condition, however muscle symptoms replace them.


Treatment (described in the following sections)

The anatomic structure(s) causing the pain determine the treatment. The anterior and pivotal appliance, along with home care, sets up conditions for healing.    1. Muscles: anterior appliance    2. Joint: pivotal appliance The pivotal lightens the pressure within the joint (11) .


The two appliances

Never is either appliance worn while eating!

Anterior Appliance

Pivotal Appliance
The pivotal appliance is a bilateral appliance and is never used singly.


Home care disciplines for muscle and joint soreness

1. MOST IMPORTANT DISCIPLINE -- Sleep on your back and avoid all pressure on your jaw. Use only a low pillow or no pillow when you sleep. The reason most people roll over is that their back begins to hurt. A very good technique for avoiding this is to place one or two pillows under your knees. It is very hard to change sleep habits, so do not give up, as much as 6 months is sometimes needed to change sleeping positions. If you cannot sleep on your back, sleep on your side and support your head with enough pillow height to keep your spine straight. Put the pillow high enough on your head to avoid pressure anywhere on the jaw.

  2. Avoid caffeine-containing beverages and foods. The intake of coffee, Mountain Dew, cola, diet cola, tea, chocolate, etc. should be very carefully monitored and curtailed. The caffeine contained in one cup of coffee is the maximum amount a person should consume in a day. Caffeine is an interesting drug. Caffeine can get rid of a headache, but it also causes headaches. Reducing your intake of caffeine "cold turkey" will bring on headaches in many people. You may need to take ibuprofen (400 - 800 mg. four times a day), read the warnings on the packaging to control a withdrawal headache from caffeine.

  3. Eat a soft diet and avoid chewing as much as possible. Absolutely no gum chewing.

  4. Use the anterior deprogramming device once in the morning and once at night, if directed to do so. Apply warm moist heat (moist wash cloth over heating pad) to sore area if needed. If we made an appliance for you, this does not apply.

  5. Avoid clinching your teeth during the day. A good technique for catching yourself clinching is to program your brain to think, "Am I clinching my teeth?" You can use everyday events to "jog" your memory. Think! Every time you look at your watch (before you even think of the time) or walk through a door, try to catch yourself clinching  with a little practice, this technique is very effective in preventing TMD headache during your waking hours. In addition, small "sticky dots" from a stationary store can remind you not to clinch. Put one wherever it will be a good reminder.

  6. Take your medications. Initially, this helps to gain control of symptoms more rapidly by decreasing inflammation. If you feel an allergic reaction is occurring -- discontinue medication use immediately.

  7. Wear your appliance! You can decrease the wear time of the anterior appliance as soon as you start to feel better. The pivotal appliance needs a 6 to 18-month period of almost continuous wear to accomplish our goals. Never wear either appliance when you eat -- ever.

  8. It is your responsibility to maintain contact with the office. We will try very hard to maintain this contact, but it is difficult. If you start to have pain in the future, call us. We can generally save you a lot of time and aggravation. A monthly check appointment is essential, especially for the pivotal. Never wear your pivotal appliance singly because the appliance will cause harm. Call if you have a problem or if your appliance is making the symptoms worse. Call immediately if the pain starts to center in or around your ear.