Oral

Temporomandibular (TM) Disorders

Temporomandibular (TM) disorders is the name given to several problems with jaw movement and pain in and around the jaw joints. You may also hear TM disorders called TMJ, TMD, or TM problems.

The jaw joints, or temporomandibular (TM) joints, connect the lower jawbone (mandible) to the skull. These flexible joints are used more than any other joint in the body. They allow the jaw to open and close for talking, chewing, swallowing, yawning, and other movements.

Many people have problems with jaw movement and pain in and around the jaw joints at some time during their lives. These joint and muscle problems are complex. So finding the right diagnosis and treatment of TM disorders may take some time.

TM disorders can affect the jaw and jaw joint as well as muscles in the face, shoulder, head, and neck. Common symptoms include:

  • Joint pain
  • Muscle pain
  • Headaches
  • Joint sounds
  • Trouble with fully opening the mouth
  • Jaw locking

In most cases, symptoms of TM disorders are mild. They tend to come and go without getting worse and usually go away without a doctor’s care.

Some people who have TM disorders develop long-lasting (chronic) symptoms. Chronic pain or difficulty moving the jaw may affect talking, eating, and swallowing. This may affect a person’s overall sense of well-being.

The most common cause of TM disorder symptoms is muscle tension, often triggered by stress. When you are under stress, you may be in the habit of clenching or grinding your teeth. These habits can tire the jaw muscles and lead to a cycle of muscle spasm, tissue damage, pain, and sore muscles.

TM disorders can start when there is a problem with the joint itself, such as:

  • An injury to the joint or the tissues around it.
  • Problems with how the joint is shaped.
  • Joint diseases, such as osteoarthritis or rheumatoid arthritis.
  • The articular disc that cushions the joint shifts out of place.

TM disorder symptoms usually go away without treatment. Simple home treatment can often relieve mild jaw pain. There are things you can do at first to reduce pain.

  • Rest your jaw joint.
  • Use medicines for a short time, to reduce swelling or relax muscles.
  • Put either an ice pack or a warm, moist cloth on your jaw for 15 minutes several times a day if it makes your jaw feel better. Or you can switch back and forth between moist heat and cold. Gently open and close your mouth while you use the ice pack or heat. But don’t use heat if your jaw is swollen. Use only ice until the swelling is gone.
  • Eat soft foods.
  • Avoid chewy foods and chewing gum.

Splints, also called bite plates, are a common dental treatment for TM disorders. Splints are usually clear pieces of plastic that fit between the upper and lower teeth. They help reduce grinding and clenching. Splints are used for a short time so that they do not cause permanent changes in the teeth or jaw.

Getting physiotherapy and learning ways to reduce stress may also help to reduce pain and TM joint problems. If your pain is chronic or severe or is caused by problems with how the joint is shaped, your doctor may recommend other treatments such as surgery or reshaping or shaving down the teeth.

Phantom Tooth Syndrome

Phantom tooth syndrome is an orofacial pain disorder that causes lingering pain in the teeth without a clear cause. Clinically, phantom tooth pain is similar in many essential characteristics to phantom limb syndromes experienced by amputees.

Phantom tooth syndrome can cause significant, persistent pain in the teeth that may last for months and even years. The severity of pain can vary and it may occur by itself or is triggered by something, such as hot, cold or a light touch. In many instances, pain starts after a patient has had a dental procedure, such as a root canal or filling. In addition, the tooth may even be extracted and can continue to hurt as if it were still there.

The incidence of phantom tooth pain after extraction may be as high as 3% of cases.

Treatment for phantom tooth pain can be frustrating for patients and dentists. Pain may persist in teeth that have had the nerve removed, or even in areas where a tooth has been extracted. Treatments consist of three routes of drug administration: oral, nerve blocks by injections, and intranasal applications. In an attempt to treat to the pain, many patients undergo additional unnecessary dental procedures.

Nerve Injury

Nerve injury can sometimes result from dental treatments such as dental injections, root canals, insertion of dental implants and removal of teeth or other surgical treatments. These injuries affect the trigeminal nerve. The trigeminal nerve is responsible for sensation in the face. It also has certain motor functions (biting, chewing, and swallowing).

Trigeminal neuralgia (TN) is a neuropathic disorder characterized by episodes of intense pain in the face that originates in one of the three trigeminal nerves. This pain may be felt in any or all of the following: the ear, eye, lips, nose, scalp, forehead, cheeks, teeth, or jaw and alongside of the face, or in some cases, the left index finger.

It is estimated that 1 in 15,000 people suffer from trigeminal neuralgia, although the actual figure may be significantly higher due to frequent misdiagnosis. In a majority of cases, TN symptoms begin appearing after the age of 50, although there have been cases with patients being as young as three years of age. It is more common in females than males.

Nerve injuries affecting the trigeminal nerve can cause episodes of intense, stabbing, electric shock-like pain in the areas of the face where the branches of the trigeminal nerve are distributed, including the lips, eyes, nose, scalp, forehead, upper jaw and lower jaw.

Trigeminal nerve injuries can be extremely distressing for patients. Although the majority of patients regain normal sensation and function within a few weeks or months, some are left with abnormal sensation or pain, which can cause problems with speech and chewing.

While medications may be used to manage many cases of nerve injury, they do not provide a permanent solution. Some patients may require surgery. Some of surgical approaches for TN, include:

  • Nerve decompression
  • Nerve repair from inside and outside of the mouth
  • Nerve grafting using nerves from the neck and foot
  • Percutaneous rhizotomy, a procedure that destroys part of the nerve that causes pain
  • Gamma Knife radiosurgery

Jaw Tumors and Cysts

Cysts and tumors can occur in and around the jaw and structures of the teeth. These include benign tumors and cysts, which are non-cancerous; those that are aggressive and growing, with the potential to become cancerous; and tumors that are malignant, meaning that they are cancerous.

Because the mouth and jaws are composed of many different types of tissues, such as bone, muscle, glands and mucosa (the tissue that covers the cheeks, lips and gums), they are more susceptible to developing abnormal growths than other parts of the body.

Although tumors and cysts of the jaw can affect anyone, a number of risk factors have been identified that increase a person’s chance of developing them. The main risk factors are:

  • Smoking
  • Alcohol
  • Poor oral hygiene
  • Irritation caused by ill-fitting dentures
  • Rough surfaces on teeth
  • Poor nutrition

Fortunately, changes inside the mouth are often easily seen and detected. If you notice something abnormal or new in your mouth, you should contact your doctor immediately.

Signs and symptoms of jaw tumors and cysts include the following abnormalities, which are located in or around the jaws or structures of the teeth:

  • Reddish patches, called erythroplasia
  • Whitish patches, called leukoplakia
  • A sore that does not heal and bleeds easily
  • A lump or thickening of the tissues
  • Chronic sore throat or hoarseness
  • Difficulty in chewing or swallowing

Treatment will depend on whether your tumor or cyst is benign or malignant. Surgical treatments aim to remove the tumor or cyst. In addition to surgery, chemotherapy and radiation therapy also may be recommended for treatment if your tumor is cancerous.

Dental Implants

A dental implant is an artificial tooth root used in dentistry to support restorations that resemble a tooth or group of teeth.

Dental implants are an excellent solution for the millions of people who have permanently lost a single tooth, many teeth or for those who use dentures. Made of materials that are compatible with human bone and tissue, dental implants provide artificial teeth that look natural and feel secure. They can also be used to attach full or partial dentures.

Conventional dentures and bridges:

  • Are often uncomfortable
  • May limit a person’s ability to speak
  • May limit a person’s ability eat normally due to slippage
  • People feel self-conscious wearing their dentures

Dental implants can greatly enhance a person’s quality of life by providing the following:

  • Restoring normal chewing and speaking functions
  • Increasing your confidence by replacing teeth that won’t move or loosen and have the same look, feel and function of your natural teeth
  • Eliminating irritated and painful gums, as well as damaging pressure on remaining natural teeth caused by dentures
  • Helping to stop the progressive bone loss and shrinkage of your jawbone by “mimicking” the roots of natural teeth

Patients who receive dental implants must be in good health, have a healthy lifestyle and healthy gums, adequate bone to support implants and be committed to excellent oral hygiene and regular dental visits. If your surgeon determines that you are an appropriate candidate for the procedure, he/she will work in close collaboration with your dentist to develop a dental implant treatment program.

Implant procedures are performed either in a dental office or hospital, depending on a variety of factors. A local or general anesthetic may be used to relax you during the procedure. Following surgery, pain medication and antibiotics may be prescribed if necessary.

In most cases, dental implant surgery involves two procedures. The entire process, from evaluation to completion, usually takes six to eight months.

The procedure involves two main steps:

  • Placement of Implants: First, implants are surgically placed into your jawbone. These devices, which are typically made of titanium, form the framework for securely holding replacement teeth. This procedure can take up to six hours. Some patients experience minor pain and swelling immediately afterwards, although your surgeon can prescribe you a medication to relieve any discomfort.For the next three to six months following surgery, the implants begin to bond with your jawbone beneath your gums (osseointegration). During this period, you will able to wear temporary dentures, eat soft food and continue your normal daily routine.
  • Placement of Artificial Teeth: Once your implants have completely bonded with your jawbone, the second phase of the procedure will be performed. Your oral and maxillofacial surgeon will uncover the implants and attach small posts that act as anchors for the artificial teeth, which are specially designed by a dentist with training in restorative techniques.

The vast majority of patients are extremely happy with their dental implants and experience a significant improvement in their quality of life.

To achieve long-term success with your dental implants, proper brushing, flushing, rinsing and routine dental check-ups are essential. Your surgeon will discuss your follow-up care in more detail after your dental implant procedure.

Cold Sores

Cold sores, sometimes called fever blisters, are groups of small blisters on the lip and around the mouth. The skin around the blisters is often red, swollen, and sore. The blisters may break open, leak a clear fluid, and then scab over after a few days. They usually heal in several days to 2 weeks.

Cold sores are caused by the herpes simplex virus (HSV). There are two types of herpes simplex virus: HSV-1 and HSV-2. Both virus types can cause sores around the mouth (herpes labialis) and on the genitals (genital herpes).

The herpes simplex virus usually enters the body through a break in the skin around or inside the mouth. It is usually spread when a person touches a cold sore or touches infected fluid — such as from sharing eating utensils or razors, kissing an infected person, or touching that person’s saliva. A parent who has a cold sore often spreads the infection to his or her child in this way. Cold sores can also be spread to other areas of the body.

There are some things you can do to keep from getting the herpes simplex virus.

  • Avoid coming into contact with infected body fluids, such as kissing an infected person.
  • Avoid sharing eating utensils, drinking cups, or other items that a person with a cold sore may have used.

The first symptoms of cold sores may include:

  • Pain around your mouth and on your lips
  • A fever
  • A sore throat
  • Swollen glands in your neck or other parts of the body

Small children sometimes drool before cold sores appear. After the blisters appear, the cold sores usually break open, leak a clear fluid, and then crust over and disappear after several days to 2 weeks. For some people, cold sores can be very painful.

Some people have the virus but don’t get cold sores. They have no symptoms.

Cold sores will usually start to heal on their own within a few days. But if they cause pain or make you feel embarrassed, they can be treated. Treatment may include skin creams, ointments, or sometimes pills. Treatment may get rid of the cold sores only 1 to 2 days faster, but it can also help ease painful blisters or other uncomfortable symptoms.

The herpes simplex virus that causes cold sores cannot be cured. After you get infected, the virus stays in your body for the rest of your life. However, there are a number of things you can do to reduce your number of outbreaks and prevent spreading the virus, including:

  • Avoid the things that trigger your cold sores, such as stress and colds or the flu.
  • Always use lip balm and sunscreen on your face. Too much sunlight can cause cold sores to flare.
  • Avoid sharing towels, razors, silverware, toothbrushes, or other objects that a person with a cold sore may have used.
  • When you have a cold sore, make sure to wash your hands often, and try not to touch your sore. This can help keep you from spreading the virus to your eyes or genital area or to other people.
  • Talk to your doctor if you get cold sores often. You may be able to take prescription pills to prevent cold sore outbreaks.

Cleft Lip and Palate

A cleft lip is a separation of the two sides of the lip, usually involving the bones of the upper jaw, upper gum, or both. A cleft palate is an opening in the roof of the mouth in which the two sides of the palate did not fuse or join together properly. Cleft lip and cleft palate can occur on one side or both sides.

The fourth most common birth defect in North America, cleft lip and cleft palate affect one in every 700 newborns each year. The highest prevalence rates are reported for Native Americans and Asians. Africans have the lowest prevalence rates.

Because cleft lip and cleft palate are apparent at birth, most people have surgery to correct the defect early in life.

However, follow-up surgery often is necessary later on to treat any deformities that still exist after initial treatment. These may include:

  • Crooked, poorly shaped or missing teeth
  • Misalignment of teeth and jaw
  • Deformities of the upper jaw, known as the maxilla
  • Speech problems
  • Un-repaired oronasal fistulae, which is a hole between the mouth and nose cavity. This hole may allow substances in the mouth to enter the nose cavity, resulting in infection
  • Alveolar clefts, which are defects in the bone that supports the teeth

Treatment for cleft lip and palate involves surgery and may include:

  • Bone grafting — Although bone grafting is most frequently performed on children under the age of 10, adults also can benefit from the procedure. Bone grafting in the dental ridge of the upper jaw, called the maxilla, is now the standard treatment for patients with facial clefts. The procedure involves taking a small amount of bone from one place — usually the hip, head, ribs or leg — and placing it in the area of the cleft near the teeth.
  • Surgical Closure of Oronasal Fistulae — An oronasal fistulae is a hole between the mouth and nose cavity. Fistulae can be problematic in that they allow substances in the mouth, such as liquids and foods, to enter into the nose cavity, resulting in infection. In rare cases, when fistulae become very large, they create speech problems.Most fistulae can be surgically closed using local tissue from the roof of the mouth, the tongue or the inside cheek.
  • Dental implants –Many people with cleft lip and palate have one or more missing teeth. In addition, their teeth adjacent to the cleft often have a deficiency of supporting bone. In these instances, osseointegrated implants are the most effective approach for replacing missing teeth.The dental implants are small titanium “fixtures” that take the place of the natural root of the tooth. Your surgeon will gently implant them into your bone, using local anesthesia. These very tiny titanium roots will then bond or integrate with your bone, more securely than natural root would. These implants serve as an “anchor” for permanent artificial teeth, which are built and custom designed to aesthetically suit your facial features by a prosthodontist — a dentist who specializes in the restoration and replacement of teeth.

Velocardiofacial Syndrome

Velocardiofacial syndrome (or VCFS) is known by many names, including Shprintzen Syndrome, Craniofacial Syndrome, or Conotruncal Anomaly Face Syndrome. The name velocardiofacial syndrome comes from the Latin words “velum” meaning palate, “cardia” meaning heart, and “facies” having to do with the face.

Velocardiofacial syndrome is the most common syndrome associated with a cleft palate. It is estimated that 1 in 2,000 to 5,000 children per year are born with velocardiofacial syndrome, and over 130,000 individuals in North America have this syndrome.

While the exact cause of velocardiofacial syndrome remains unknown, investigators have identified an associated chromosomal defect in people with velocardiofacial syndrome. Most children identified as having velocardiofacial syndrome are missing a small piece of chromosome 22. This so-called “deletion” is located at a region of the chromosome called 22q11.2. Which gene or genes located on this part of chromosome 22 are missing and responsible for causing the features of velocardiofacial syndrome remain unknown. There is a genetic test for the diagnosis of this condition called a “FISH analysis” that can be performed in many medical centers.

In studying some families with velocardiofacial syndrome, scientists have determined that it is an autosomal dominant disorder. This means that only one of the parents needs to have the chromosomal change in order to pass it along to a child. A parent with velocardiofacial syndrome has a 50/50 chance of having a child with it. However, it is estimated that velocardiofacial syndrome is inherited this way in only 10 to 15 percent of cases. Most of the time neither of the parents has the syndrome nor carries the defective gene and the cause of the deletion is called “sporadic”.

Deletions in this area of chromosome 22 have also been associated with other syndromes, including DiGeorge syndrome and one type of OPITZ G/BBB syndrome.

VCFS includes many common features:

  • Cleft palate
  • Heart defects
  • A characteristic facial appearance

Other common findings include minor learning problems and speech and feeding problems.

Since the initial description of this syndrome, many other parts of the body have been reported to be involved. Many of the affected body systems are:

  • Immune system – helps to fight off infections
  • Endocrine system – the series of glands that secrete important hormones for normal growth and development
  • Neurological system – brain control centers for learning, speech and hearing, and moods

Research shows that children with velocardiofacial syndrome are born with these features and that they do not progress over time. It is important to realize none of these occurs 100 percent of the time. Knowing which body systems are affected will help your doctors provide you and your child with the most complete therapeutic interventions.

Problems associated with velocardiofacial syndrome include:

  • Long face with prominent upper jaw
  • Flattening of the cheeks
  • Underdeveloped lower jaw
  • Bluish color below the eyes
  • Prominent nose with narrow nasal passages
  • Thin upper lip with a down-slanted mouth
  • Learning disabilities in one or more areas
  • Hearing loss
  • Speech problems
  • Extremes of behaviors/mood swings
  • Multiple abnormalities of the heart including:

Depending on the presence and severity of various features, any child with VCFS might need one or more of the following surgeries:

  • Repair of heart defects
  • Repair of cleft palate
  • Repair/reconstruction of the lower jaw
  • Reconstructive surgery of the ears

Stuttering

Stuttering is a speech disorder in which sounds, syllables, or words are repeated or prolonged, disrupting the normal flow of speech. These speech disruptions may be accompanied by struggling behaviors, such as rapid eye blinks or tremors of the lips. Stuttering can make it difficult to communicate with other people, which often affects a person’s quality of life.

Roughly three million North Americans stutter. Stuttering affects people of all ages. It occurs most often in children between the ages of 2 and 5 as they are developing their language skills. Approximately 5 percent of all children will stutter for some period in their life, lasting from a few weeks to several years. Boys are twice as likely to stutter as girls; as they get older, however, the number of boys who continue to stutter is three to four times larger than the number of girls. Most children outgrow stuttering. About 1 percent or less of adults stutter.

Symptoms of stuttering can vary significantly throughout a person’s day. In general, speaking before a group or talking on the telephone may make a person’s stuttering more severe, while singing, reading, or speaking in unison may temporarily reduce stuttering.

Although the precise mechanisms are not understood, there are two types of stuttering that are more common.

Developmental stuttering occurs in young children while they are still learning speech and language skills. It is the most common form of stuttering. Some scientists and clinicians believe that developmental stuttering occurs when children’s speech and language abilities are unable to meet the child’s verbal demands. Developmental stuttering also runs in families.

Neurogenic stuttering may occur after a stroke, head trauma, or other type of brain injury. With neurogenic stuttering, the brain has difficulty coordinating the different components involved in speaking because of signaling problems between the brain and nerves or muscles.

A third type of stuttering, called psychogenic stuttering, can be caused by emotional trauma or problems with thought or reasoning. Psychogenic stuttering is rare.

Although there is currently no cure for stuttering, there are a variety of treatments available. The nature of the treatment will differ, based upon a person’s age, communication goals, and other factors. If you or your child stutters, it is important to work with a speech-language pathologist to determine the best treatment options.

For very young children, early treatment may prevent developmental stuttering from becoming a lifelong problem. Certain strategies can help children learn to improve their speech fluency while developing positive attitudes toward communication. Health professionals generally recommend that a child be evaluated if he or she has stuttered for three to six months, exhibits struggle behaviors associated with stuttering, or has a family history of stuttering or related communication disorders. Some researchers recommend that a child be evaluated every three months to determine if the stuttering is increasing or decreasing. Treatment often involves teaching parents about ways to support their child’s production of fluent speech. Parents may be encouraged to:

  • Provide a relaxed home environment that allows many opportunities for the child to speak. This includes setting aside time to talk to one another, especially when the child is excited and has a lot to say.
  • Refrain from reacting negatively when the child stutters. Instead, parents should react to the stuttering as they would any other difficulty the child may experience in life. This may involve gentle corrections of the child’s stuttering and praise for the child’s fluent speech.
  • Be less demanding on the child to speak in a certain way or to perform verbally for people, particularly if the child experiences difficulty during periods of high pressure.
  • Speak in a slightly slowed and relaxed manner. This can help reduce time pressures the child may be experiencing.
  • Listen attentively when the child speaks and wait for him or her to say the intended word. Don’t try to complete the child’s sentences. Also, help the child learn that a person can communicate successfully even when stuttering occurs.
  • Talk openly and honestly to the child about stuttering if he or she brings up the subject. Let the child know that it is okay for some disruptions to occur.

Many of the current therapies for teens and adults who stutter focus on learning ways to minimize stuttering when they speak, such as by speaking more slowly, regulating their breathing, or gradually progressing from single-syllable responses to longer words and more complex sentences. Most of these therapies also help address the anxiety a person who stutters may feel in certain speaking situations.

Some drugs that are approved to treat other health problems—such as epilepsyanxiety, or depression—have been used to treat stuttering. These drugs often have side effects that make them difficult to use over a long period of time.

Some people who stutter use electronic devices to help control fluency. For example, one type of device fits into the ear canal, much like a hearing aid, and digitally replays a slightly altered version of the wearer’s voice into the ear so that it sounds as if he or she is speaking in unison with another person. In some people, electronic devices help improve fluency in a relatively short period of time.

Many people find that they achieve their greatest success through a combination of self-study and therapy. Self-help groups provide a way for people who stutter to find resources and support as they face the challenges of stuttering.

Jaw Deformities

Jaw deformities are a common condition, ranging from mild abnormalities to more severe defects that can be surgically corrected. In some instances, the upper or lower jaw — or both — may grow too little or too much, resulting in the improper alignment of the teeth in relation to the first molars (malocclusion).

Besides growth differences between your upper and lower jaws, jaw deformities may be caused by genetic factors, trauma and certain birth defects, such as cleft lip and cleft palate.

Jaw deformities can lead to problems with speaking, chewing, swallowing and breathing. The condition also may cause undo stress on your temporomandibular joint (TMJ) and facial muscles, affecting the long-term health of your gums and teeth. Jaw deformities also may cause pain, degeneration and jaw clicking.

In addition, improper alignment of your jaws and teeth may affect the entire appearance of your face. Correcting your jaw deformity may greatly improve your facial aesthetic. You may have one of the following aesthetic problems due to your jaw deformity:

  • “Underbite” or “overbite,” caused by malocclusion — the improper alignment of the teeth in relation to the first molars
  • “Gummy smile,” in which your upper jaw has grown too far down
  • “Long face syndrome,” in which you have an open bite with a long looking face
  • “Toothless smile,” in which your upper jaw is too small

Jaw deformities caused by unequal jaw growth can be surgically corrected. Treating your jaw deformity will eliminate or greatly reduce any problems related to your condition, such as chewing, breathing and speaking difficulties, as well as restore the aesthetic balance of your entire face.

Some people require orthodontic treatment, such as braces or other appliances, to align their teeth properly before corrective jaw surgery. In these cases, your oral and maxillofacial surgeon will work closely with an orthodontist to coordinate your care to prepare you for surgery.

Corrective jaw surgery involves moving all or part of the upper or lower jaw, or both, into a more balanced position. The majority of the surgery is performed inside the mouth without any external scarring. A hospital stay and recovery period may be necessary for more involved surgeries, while minor procedures can be performed on a same-day basis.

After the jaws are moved into their new position, rubber bands or wires attached to the teeth may be used to fasten the jaws together during healing. In other instances, miniature screws and plates are used to allow you to open and close your jaws sooner after corrective surgery.

All corrective jaw surgeries require an extensive healing time. After surgery, the jaw is fragile and sensitive, requiring two to three months for healing.