25th January 2017

Click go the jaws boys….

(with apologies to Slim Dusty…and girls!!)

 

Patients often ask me about incidentally clicking jaws. You know, that innocuous question at the end of a treatment when you’re already half an hour behind, “…by the way, I’ve been meaning to ask you…”

The question will often sound like “…I’ve had this clicking jaw for ages that doesn’t really bother me but is it something that I need to worry about, does it indicate a serious problem, am I going to get arthritis later in life?..” Sometimes they’re sent in by an exasperated partner who is sick of wincing during every shared meal.

 

Whilst the mind should tend immediately towards intra-articular disc displacement when a click is mentioned, there are other causes of joint noises that need to be differentiated before giving advice about seriousness and prognosis.

 

Having said that, there is little doubt that a clicking jaw usually does indicate some loss of integrity of the intra-articular disc / condylar relationship. The generally accepted, somewhat simplified, classic explanation (von Piekartz 2007) is that the disc, due to collateral ligament instability, has aberrantly moved anteriorly and/or  usually medially to the condyle at maximum mouth closure. When the mouth opens, the condylar head is forced to travel over the posterior band of the disc in order to re-establish its proper position and allow free and normal translation. This movement onto the disc is accompanied by an audible click or pop, often with a deviation of the mental protuberance of the mandible towards the affected side, which then swings back to the midline once the disc has been recaptured.

 

As the mouth closes, just before maximal intercuspation, the condyle again slips behind the disc with another click (usually softer and less audible, if at all). This is so-called “reciprocal clicking” and accounts for most long-term jaw clicking sensations. Long standing, stable, consistently reproducible, reciprocal clicking is often associated with fibrotic adhesions in the upper joint space, thus anchoring the disc fairly firmly to the articular surface of the eminence, in this anteriorly displaced position. This situation, with a few exceptions, is generally resistant to change via manual therapy and may require long term dental appliance therapy to attempt disc “recapture” via mandibular repositioning. Splint therapy may then need to be followed by orthodontic occlusal reconstruction in order to stop the bite recreating the conditions that led to the instability in the first place.

 

One must seriously consider the cost / benefit in determining whether to recommend this costly commitment if the click can be managed successfully by less heroic procedures (see below).

 

Not every clicking jaw however, is caused by the above scenario.

Sometimes, a hypermobile TMJ can make a dullish, thud / clunk at the end of mouth opening. This is sometimes accompanied by a palpable or visible lateral prominence of the condyle at this point (von Piekartz 2007). An iterincisal opening measurement in the 55-60mm and above range, plus positive signs of general hypermobility syndrome, ( e.g. genu / cubital recurvatum, positive palms to floor, thumb to forarm test etc), makes this aetiology more likely. Statistically there is a peak in jaw clicking in teenage girls that is generally considered to be due to hypermobility. One should be cautious about recommending expensive, large scale treatment programs for such individuals because low- tech management, based around exercises to maintain function and optimise stability, usually suffices until skeletal and ligamentous maturity improves in the 20’s.( Könönen 1996, Anthony1993)

 

Another important cause of joint clicking might be the rubbing or snapping noise created by soft tissue adhesions or anatomical variations of the ligaments and muscles of mastication (von Piekartz 2007). These sounds are often distinguishable from the above by the gradual diminishment of the amplitude of the noise on repeated mouth openings in a short interval (>10) or by a probationary trial of myofascial therapy, transverse friction massage or joint mobilization.

 

Intra articular adhesions or loose bodies, (created by fragments of tissue detaching from the disc or articular surfaces of the fossa and condyle), may be other sources of clicking. These clicks are often associated with hypomobility and short term, intermittent, hard end-feel locking that seems to be alterable by the patient’s self manipulation of the mandible or therapeutically administered gapping or caudal distraction techniques. If a loose body is suspected then referral for an MRI can often clarify the diagnosis.

 

Of course the other joint noise that we should all be capable of diagnosing fairly accurately is the multiple, gritty sounds of crepitus. X-rays that show the characteristic flattening of the condylar head may confirm the suspicion of DJD.

 

So when that “click” question comes your way, you need to consider the above. A thorough history, examination, imaging and, possibly a therapeutic trial, may be necessary to determine the aetiology. Whilst a clicking jaw is not good, I rarely recommend large scale, expensive treatment programs to manage clicking that is not painful, not associated with locking nor particularly troublesome. The use of exercises, and/or a short course of therapeutic manual therapy can often lessen the amplitude and impact of a clicking jaw. (Anthony 1993)

 

Dental treatment required to eliminate a click in the absence of other TMJ symptoms is not warranted. A wait-and-see approach will not see you exposed to future accusations of negligence as there is evidence suggesting a conservative approach is best in this situation (Magnusson 2000).

 

Next issue of this publication I will outline some treatment procedures that might be trialled in such cases.

 

 

I am happy to receive your emails or phone calls with any TMJ related queries.

rmottram@tpg.com.au , 0419363649

 

 

 

References:

Anthony R, Klineberg I, 1993 Isokinetic exercise management of temporomandibular joint clicking in young adults. Journal of Prosthetic Dentistry Volume 70 Issue 1

 

Könönen M, Waltimo A, Nystrom M 1996 Does clicking in adolescence lead to painful temporomandibular joint locking? Lancet 347:1080

 

von Piekartz H 2007 Craniofacial Pain. Elsevier Ltd, pp217-219

 

Magnusson T, Egermark I, Carlsson G 2000 A longitudinal epidemiologic study of signs and symptoms of temporomandibular disorders from 15 to 35 years of age. J Orofac Pain Fall;14(4):310-9

 

 

 

 

 

 

 

 

 

 

31st August 2016

Some interesting research suggesting that poor dental occlusion and /or mouth breathing might be associated with greater incidence of allergic rhinitis

http://www.ncbi.nlm.nih.gov/m/pubmed/26631324/?i=1&from=rhinitis+malocclusion

4th June 2016

Orofacial myology seeks to retrain the lips to seal and the tongue to rest gently in the roof of the mouth. The forces applied to the teeth by these soft tissues are important for the formation of the dental bite initially and for retention of changes sought by orthodontics. One of the biggest issues with orthodontics is the relapse of the teeth after the braces are removed. This study shows how relapse can be minimised by orofacial muscle retraining.

http://www.ncbi.nlm.nih.gov/pubmed/20451779/

Tongue and lip tie can affect breastfeeding ability in infants. It should be looked for and corrected if breastfeeding is an issue.

Check out this little video

16th May 2016

Some interesting new research validating the positive effects of orofacial myology exercises for mild to moderate sleep apnoea. From the journal “Sleep Breath”.

http://www.ncbi.nlm.nih.gov/pubmed/26993338/

 

 

5th March 2016

Nose blockage, mouth breathing, decreased oxygen, can be a significant health issue. This slide show provides one perspective on nasal obstruction. Possible surgical options for chronic nasal obstruction and mouth breathing are discussed. Other options may be available such as allergy management, orofacial myology therapy etc. worth a read.