TMD- The “Bermuda Triangle” of Medical Conditions by Darron Goralsky

TMD or Temporomandibular Disorder is an umbrella term for conditions involving the temporomandibular joint and associated structures. This includes joint, disc and muscle related conditions resulting in pain and dysfunction.

Covid has resulted in an explosion of cases of TMD and resulted in a ‘perfect storm’. We all know that in the last 2.5 years stress levels have increased, while at the same time computer / screen time has also increased with working from home being the new norm and often in less than ergonomic set-ups. Additionally, for long periods, lockdown restrictions and inability to participate in their usual group-based exercise, also meant that people's ability to counter the stress and long periods of desk based work / study, was being affected.

As a clinician of 29 years I am of the strong belief that this is a poorly understood group of conditions for a number of reasons.

Firstly, the mechanics of TMJ function relies significantly on the cranio-cervical articulation which participates in the hinging phase of TMJ opening. Additionally the submandibular musculature have anatomical connections to the anterior aspects of the cervical spine. This interdependent relationship must therefore be factored into assessment and treatment of these disorders. Failure to acknowledge and address those aspect results in suboptimal outcomes

Secondly many of the associated symptoms that TMD sufferers experience are in fact generated by the structures in the cranio -cervical region and form part of the overall pain or clinical picture. “Ear” symptoms or headache for example may have a spinal origin (musculoskeletal). Since these aspects are not accounted for in the DC TMD classification system (2014) they are not considered part of the diagnosis (and therefore the management).

Thirdly, As a result of the convergence of C1/2/3 afferents with the Trigeminal Nerve via the Trigeminocervical nucleus, symptoms in the trigeminal distribution may in fact have a cervical origin (and Visa Versa). This can create confusion as to the actual source of pain or dysfunction.

Additionally - it’s very important to understand the close relationship of the airway to TMJ function. Conditions such as upper airway resistance syndrome (UARS) and obstructive sleep apnoea (OSA) can also result in clenching and grinding and other symptoms common to TMD. Recognising and addressing these conditions as primary medical conditions must always be factored in to management. For this reason our multidisciplinary team includes dentists who specialise in TMD and dental sleep medicine. We work closely with them to determine the root cause of issues and then formulate the most appropriate management and treatment plan.

Finally - As a result of this poorly understood connection, patients will often pursue an investigation and treatment path in-line with their most prevalent symptoms they are suffering from. This may be a neurological path in the case of headaches, a dental path if the pain is more obviously affecting TMJ function or their ability to eat, or an ENT path when ‘sinus’ or ‘ear’ type symptoms prevail. Unfortunately, unless they consult a medical or allied health professional who understands the interconnectedness of all of the above mentioned, these patients are very likely to become lost in the system without achieving the results they require to return to healthy function. This is what we see daily in our practice and patients bemoan the fact that despite their extensive efforts to find solutions, they feel that they have been failed.

Recognising the complexity of these conditions and the fact that they have been poorly catered for has been the driving force behind my passion to become a part of the solution, not the problem. I have dedicated my professional focus over the last decade to better understand the moving parts in these conditions and formulate a comprehensive approach to try and achieve much better clinical outcomes. Our practice approach The Goralsky
Craniomandibular Method is ever evolving to include more techniques, clinical aspects and self help measures for our patients. We understand that there is no single ‘magic bullet’ that will address these issues. We know that a holistic approach that also addresses the patient’s emotional state and lifestyle is essential for achieving not only reprieve from the sometimes intolerable pain, but also longer term results for these oftentimes chronic conditions.

Darron Goralsky
Principal Physiotherapist & Director
Melbourne TMJ & Facial Pain Centre




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