Himachal Dental

Treatment of Temporomandibular Joint Disorder ( TMD )

Posted in Oral Surgery by UK Dental Tourism on September 24, 2010

TMD, also commonly known as TMJD, is short for temporomandibular disorder and is a condition that affects the jaw, muscles in the neck and head and the TMJ joints next to each ear. The TMJ joint is responsible for coordinating movements that lead to eating, drinking and talking so any complaint in the area can have a significant impact on the life of the patient.

The main symptom of TMJ is unfortunately pain. This usually occurs when the patient is chewing or yawning, or any other extended movement of the TM joint. There may also be a painful ringing or tinnitus in the ear. Other major symptoms include swelling around the joint, a change in the bite and profile and trouble swallowing.In TMJ disorders, the joint can be affected by injury, arthritis, general wear and tear or degenerative joint disease. The disk of cartilage that cushions the joint can also become damaged or displaced, leading to a loss of flexibility or range of motion for the joint. Patients often experience pain, difficulty opening and closing their jaw or even hear a “clicking” or “popping” sound when using the joint.

One of the major problems when diagnosing TMJ is that a lot of these symptoms can be caused by manifold other conditions, some of which are far more likely to occur. This means that TMJ is often far down the list of diagnoses. Your dentist, if suspects TMJ, will conduct something called a clench test. This involves clenching the jaw to assess whether there is a structural disorder that could be TMd.

In most cases, treatment of TMJ will involve some level of orthodontics. In some severe cases, there may be a need for surgery but most bite misalignments can be cured with orthodontic treatment. During treatment, it may be necessary to wear a mouth guard to protect the lower teeth.

Symptoms can be treated with anti-inflammatory medications, bite splints or physical therapy techniques. But for patients with lasting TMJ pain, a consultation with an oral maxillofacial surgeon or a TMJ/oro-facial pain specialist can bring them more options to ease their condition.

The most minimally invasive technique for TMJ surgery is arthrocentesis, a short procedure usually performed under IV sedation or general anesthesia. Surgeons inject the joint with local anesthetic and fluid to flush out inflamed fluids.
Arthrocentesis is effective when inflammation is limited to or focused most within the joint.

When treatment requires open surgery, or arthroplasty, surgeons have several options, including disk repositioning, discectomy and joint replacement. Because these surgeries involve more risk, including damage to the ear canal or nearby nerves, they are only used after other treatment options have been considered.

Disk repositioning: Disk repositioning is used when the cartilage disk has slipped out of place inside the joint. Once out of place, the slipped disk can cause the often noted “popping” noise inside the joint, pinch a nerve surrounding the joint or stretch or inflame the surrounding ligaments. In disk repositioning, the surgeon makes an incision, moves the displaced disk back to its original position and stitches it in place, repairing surrounding ligaments if needed. Repositioned disks can sometimes slip back or degenerate.

Discectomy: A discectomy is a full removal of the disk in the TMJ joint. Disks that are constantly out of position or pop back and forth inside the joint are good candidates for this surgery.

Articular eminance recontouring: For some patients, the articular eminence (the “socket” part of the TMJ’s ball and socket joint) can be too deep. In this treatment, the surgeon shortens and smooths the articular eminence to prevent excessive forces on the joint, improve range of motion and reduce pain.

TMJ replacement: Newer techniques and materials have made prosthetic replacement of the TMJ a feasible option for patients with end-stage TMJ degeneration. The replacements have a socket component made of dense polymer and a jaw joint head made of a mixed alloy material that is attached to the remaining jaw bone. Prostheses are recommended to be replaced every decade.

There are various other treatments your dentist will be able to explain upon diagnosis of TMJ. If your jaw joints hurt or are swollen, then contact a dentist and ask for a test for TMJ.

Lichen Planus – Chronic Inflammatory Disease

Lichen planus is a chronic mucocutaneous disease that affects the skin and the oral mucosa, and presents itself in the form of papules, lesions or rashes. Lichen planus doesn’t involve lichens; the name refers to the appearance of affected skin.The name of condition was provided by British physician Erasmus Wilson ,who first described it in 1869.Lichens are the primitive plants composed of symbiotic algae and fungi.The term planus is latin for flat.Even though the term lichen planus suggests a flat ,fungal condition ,current evidence indicates that this is an immunologically mediated mucocutaneous disorder.

The cause of lichen planus is not known. It is not contagious and does not involve any known pathogen. Some lichen planus-type rashes (known as lichenoid reactions) occur as allergic reactions to medications for high blood pressure, heart disease and arthritis. These lichenoid reactions are referred to as lichenoid mucositis (of the mucosa) or dermatitis (of the skin). Lichen planus has been reported as a complication of chronic hepatitis C virus infection and can be a sign of chronic graft-versus-host disease of the skin. It has been suggested that true lichen planus may respond to stress, where lesions may present on the mucosa or skin during times of stress in those with the disease. Lichen planus affects women more than men (at a ratio of 3:2), and occurs most often in middle-aged adults. Lichen planus in children is rare. In unpublished clinical observation, lichen planus appears to be associated with hypothyroidism in 3 young females.Allergic reactions to amalgam fillings may contribute to the oral lesions very similar to lichen planus, and a systematic review found that many of the lesions resolved after the fillings were replaced.


The typical rash of lichen planus is well-described by the “4 P’s”: well-defined pruritic, planar, purple, polygonal papules. The commonly affected sites are near the wrist and the ankle. The rash tends to heal with prominent blue-black or brownish discoloration that persists for a long time. Besides the typical lesions, many morphological varieties of the rash may occur. The presence of cutaneous lesions is not constant and may wax and wane over time. Oral lesions tend to last far longer than cutaneous lichen planus lesions.

Oral lichen planus (OLP) may present in one of three forms.

* The reticular form is the most common presentation and manifests as white lacy streaks on the mucosa (known as Wickham’s striae) or as smaller papules (small raised area). The lesions tend to be bilateral and are asymptomatic. The lacy streaks may also be seen on other parts of the mouth, including the gingiva (gums), the tongue, palate and lips.
* The bullous form presents as fluid-filled vesicles which project from the surface.
* The erosive form presents with erythematous (red) areas that are ulcerated and uncomfortable. The erosion of the thin epithelium may occur in multiple areas of the mouth, or in one area, such as the gums, where they resemble desquamative gingivitis. Wickham’s striae may also be seen near these ulcerated areas. This form may undergo malignant transformation.

The microscopic appearance of lichen planus is pathognomonic for the condition

* Hyperparakeratosis with thickening of the granular cell layer
* Development of a “saw-tooth” appearance of the rete pegs
* Degeneration of the basal cell layer
* Infiltration of inflammatory cells into the subepithelial layer of connective tissue

Oral Lichen Planus Typical Featutes

* Females account for atr 65% of patients
* Patients usually over 40 years
* Untreated disease persists for 10 or more years
* Lesions in combination or isolation comprise Striae,Atropic areas and Erosion Plaques
* Common Sites are buccal mucosa,Dorsum of tongue and Gingiva
* Lesions usually occur bilaterally ansd symmetrically
* Cutaneous lesion only ocassionlly associates .
* Usually good responce to corticosteroids

Lichen planus may also affect the genital mucosa – vulvovaginal-gingival lichen planus. It can resemble other skin conditions such as atopic dermatitis and psoriasis.Rarely, lichen planus shows esophageal involvement, where it can present with erosive esophagitis and stricturing. It has also been hypothesized that it is a precursor to squamous cell carcinoma of the esophagus.


Care of OLP is within the scope of Oral medicine speciality. Currently there is no cure for lichen planus but there are certain types of medicines used to reduce the effects of the inflammation. Lichen planus may go into a dormant state after treatment. There are also reports that lichen planus can flare up years after it is considered cured.

Some Drugs Capable Of causing Lichenoid Reactions
* Colloidal Gold
* Beta-Blockers
* Oral Hypoglycemics
* Allopurinol
* Non steroidal anti inflammatory drugs
* Anti malarials
* Methyl Dopa
* Penicillamine
* Some tricyclic anti depressants
* Thiazide diuretics
* Captopril

Features suggesting a lichenoid reactions
* Onset associated with starting drug
* Unusual severity
* Unilateral lesions or unusual distributions
* Widespread skin lesions
* Localised lesion in contact with restoration
* Lichenoid reaction are treated in same way as lichen planus with withdrawl of dtrugs if possible

Medicines used to treat lichen planus include:

* Oral and topical steroids.
* Oral retinoids
* immunosuppressant medications
* hydroxychloroquine
* tacrolimus
* dapsone
* Aloe vera

Non-drug treatments:

* UVB NarrowBand Phototherapy

Management Of Oral LP

Patients are sometimes concerned that lichen planus is infectious and should be reassured that tis is not so.Although oral lichen planus cannot be cured completely ,some drugs can provide symtomatic relief and satisfactory control.Corticosteroids are single most useful group of drugs in the management of lichen planus.The rationale of their use is their ability to modulate inflammation and the immune responce.Corticosteroids such as Beclomethasone from aerosol inhalers used for asthma can be used effectively -approx six puffs from inhaler is enough for the lesion.Triamcinole applied to the lesion is an alternative form of the treatment.Gingival lichen planus is most difficult to treat.It is essential to maintain rigourous oral hygiene .In erosive LP ,one of the stronger topical corticosteroids like Fluticasone nasal spray ,Fluocinolone,Betamathasone,Clobetasol gel applied several times per day to the most symtomatic areas is usually sufficient to induce healing within 1-2 months.The patient should be warned that he condition will undoubtedly flare up again in which case the corticosteroids should be reapplied.In addition the possibility of iatrogenic candidiasis associated with corticosteroids use should be monitored .Nystatin or Amphotericin-B suspension /Miconazole can be given in conjugation with the above.

* Always check for drugs like NSAIDS which might cause a lichenoid reaction
* Tobacco an alcohol need to be dicontinued
* Allergens need to be eliminated eg change of diet
* Infections associed with Oral Lp need to be terated eg Thrush,Hep C
* Sharp teeth and broken restorations taht cause trauma should be repaired
* Stress management ca be opted

In some cases where topical therapy fails systemic corticosteroids are effective.Antioxidants OD for Six months help improve condition.In exceptionally unresponsive cases ,tacrolimus/pimecrolimus moth rinses may be effective which must be given under strict medical supervision.Immunoregulators like levamisol have found to improve the condition of patient chronically on corticosteroids.

Extranodal Non Hodgkin Lymphoma

Posted in Oral Surgery by UK Dental Tourism on January 14, 2010

Non-Hodgkin lymphoma (NHL) is uncommon. It is the second most common group of malignancies, behind only squamous cell carcinoma.It accounts for 3.5% of intraoral malignancies but rarely arises on gingiva.Most of these are high grade diffuse large B -Cell lymphomas. Diagnosis of an NHL of the oralcavity is often diifficult bacause it may resemble other conditions such as dental abcesses or can mimic other pathological conditions  eg. fibroma ,periodontal disease.

The radigraphic aspect of NHL is also not chracteristic. Frequently,NHL presents as a local ,painless swelling without ulceration andaccompnied by pain or discomfort in the throat .These local symtoms can also be associated with systemic symtoms called  B -Symtoms.Lymphoma should be considered in he presence of a gingival swelling accompnied by tooth mobility, ulceration and unexplained dental pain or numbness.Histologic and immunophenotypic studies are therefore important in establshing the diagnosis.Most patiets with NHL of the head and neck have , at presentation , a stage 1 or 2 high grade diffuse large B-Cell Lymphoma.

According to Ann Arbor Staging Classification , the lymphomas can be classified as :

The principal stage is determined by location of the tumor:

* Stage I indicates that the cancer is located in a single region, usually one lymph node and the surrounding area. Stage I often will not have outward symptoms.
* Stage II indicates that the cancer is located in two separate regions, an affected lymph node or organ and a second affected area, and that both affected areas are confined to one side of the diaphragm – that is, both are above the diaphragm, or both are below the diaphragm.
* Stage III indicates that the cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
* Stage IV indicates diffuse or disseminated involvement of one or more extralymphatic organs, including any involvement of the liver, bone marrow, or nodular involvement of the lungs.

Modifiers.These letters can be appended to some stages:

* A or B: the absence of constitutional (B-type) symptoms is denoted by adding an “A” to the stage; the presence is denoted by adding a “B” to the stage.
* E: is used if the disease is “extranodal” (not in the lymph nodes) or has spread from lymph nodes to adjacent tissue.
* X: is used if the largest deposit is >10 cm large (“bulky disease”), or whether the mediastinum is wider than 1/3 of the chest on a chest X-ray.
* S: is used if the disease has spread to the spleen.

Type of staging

The nature of the staging is (occasionally) expressed with:

* CS – clinical stage as obtained by doctor’s examinations and tests.
* PS – pathological stage as obtained by exploratory laparotomy (surgery performed through an abdominal incision) with splenectomy (surgical removal of the spleen). Note: exploratory laparotomy has fallen out of favor for lymphoma staging.

Treatment of  extranodal NHL includes surgical excision followed by chemotherapy sometimes with associateds radiotherapy.Primary NHL of gingiva can mimic other lesions.It is therefore necessary to perform a histologic examination in cases where signs and symtoms persist,despite treatment . An yearly biopsy will provide an approprite diagnosis and avoid disease progression ,thus improving the pronosis.

Relief From Painful TMD

Posted in Oral Surgery by UK Dental Tourism on January 4, 2010
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Temporomandibular disorders (TMD) occur as a result of problems with the jaw, jaw joint and surrounding facial muscles that control chewing and moving the jaw. These disorders are often incorrectly called TMJ, which stands for  temporomandibular joint.

The cause of TMD is not clear, but dentists believe that symptoms arise from problems with the muscles of the jaw or with the parts of the joint itself.

Injury to the jaw, temporomandibular joint, or muscles of the head and neck – such as from a heavy blow or whiplash – can cause TMD. Other possible causes include:

* Grinding or clenching the teeth, which puts a lot of pressure on the TMJ
* Dislocation of the soft cushion or disc between the ball and socket
* Presence of osteoarthritis or rheumatoid arthritis in the TMJ
* Stress, which can cause a person to tighten facial and jaw muscles or clench the teeth

People with TMD can experience severe pain and discomfort that can be temporary or last for many years. More women than men experience TMD and TMD is seen most commonly in people between the ages of 20 and 40.

Common symptoms of TMD include:

* Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when you chew, speak, or open your mouth wide
* Limited ability to open the mouth very wide
* Jaws that get “stuck” or “lock” in the open- or closed-mouth position
* Clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth (which may or may not be accompanied by pain)
* A tired feeling in the face
* Difficulty chewing or a sudden uncomfortable bite – as if the upper and lower teeth are not fitting together properly
* Swelling on the side of the face

Other common symptoms of TMD include toothaches, headaches, neckaches, dizziness, earaches, hearing problems, upper shoulder pain, and ringing in the ears (tinnitis).

Because many other conditions can cause similar symptoms to TMD – including a toothache, sinus problems, arthritis, or gum disease – your dentist will conduct a careful patient history and clinical examination to determine the cause of your symptoms.Treatments for TMD range from simple self-care practices and conservative treatments to injections and surgery. Most experts agree that treatment should begin with conservative, nonsurgical therapies first, with surgery left as the last resort. Many of the treatments listed below often work best when used in combination.

Basic treatments include *   Apply moist heat or cold packs.* Eat soft foods.* Take medication To relieve muscle pain and swelling. * Low-level laser therapy.* Wear a splint or night guard.* Undergo corrective dental treatments. * Don’t rest your chin on your hand or hold the telephone between your shoulder and ear.* Keep your teeth slightly apart as often as you can to relieve pressure on the jaw. * Learning relaxation techniques to help control muscle tension in the jaw.More Controversial Treatments for TMD include * Transcutaneous electrical nerve stimulation (TENS).* Ultrasound treatment.* Trigger-point injections.* Radio wave therapy.
* Surgery for TMD .There are three types of surgery for TMD: arthrocentesis, arthroscopy, and open-joint surgery. The type of surgery needed depends on the TMD problem.

Our dentists are fully trained and equipped to diagnose and treat the pain of TMJ. If you are suffering from a painful face, jaw or neck and have been unable to get to the root of the problem with conventional diagnoses, make an appointment to see a dentist and ask about TMJ.

TMJ Disorders

If you notice a popping sound when you open your mouth, it may be time to ask your dentist about treatments for TMJ disease. In a similar way, if you tend to have headaches, facial pain, or neck pain they may all be cause by some type of malfunction of your jaw joints. Fortunately, when you visit a dentist, you will be able to receive treatment that will ease, or even eliminate your pain altogether.

In order to begin treatment, your doctor may need to conduct some tests in order to determine the cause of your jaw pain. Typically, this will involve taking xrays, as well as asking you a series of questions. Your dentist may also want to do some additional testing to see if the pain is being caused by gum disease, or other issues that cause refractory pain in the facial nerves.

Once your dentist is able to find the cause of your pain, it will be possible to treat your condition. This may include providing you with a mouth guard to prevent teeth grinding. If your dentist determines that misaligned teeth are causing your jaw pain, you may need to have braces, or other devices that will move your teeth into the correct position. Today, there are a number of dental alignment aides that cannot even be seen, let alone felt while you are wearing them.

When seeking treatment for jaw pain, it is important to realize that there are several major nerves that run through your face and neck. As a result, your pain may actually be located in the jaw, or in some other area. Therefore, your dentist will need to eliminate a number of possible issues with diagnostic testing in order to solve your problem. Fortunately, you will find that treatment for TMJ disorders will not be any worse or distressing than any other procedure designed to improve your dental health.

Tooth abscess : Causes and Treatment

Posted in Oral Surgery by UK Dental Tourism on October 7, 2009
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If a person maintains a good oral hygiene, tooth abscess will unlikely to occur. Tooth abscess is an infection of one tooth or the root of the tooth. If you have tooth abscess, it is important that you consult and seek treatment with your dentist to prevent spreading the infection to other teeth.
Tooth abscess has several causes, including:
• Existing tooth infection – when a dental procedure was performed on your tooth such as filling, root canal or crown, the infection was already in the tooth. The dental work failed to kill the bacteria which will later turned into tooth abscess.
• Weak immune system – a tooth abscess may be caused by a germ resident in the tooth and a weak immune system may have failed to fight the infection brought about by this germ.
• Age-related – as a person ages, his tooth weakens which allows a germ to enter and caused infection.

At Goma dental we may able to determine a tooth abscess because of signs and symptoms which may include:
• Persistent toothache at the site of the tooth infection
• Swelling of the tooth
• Facial swelling in cases that tooth abscess penetrated to the bone and started draining into tissues surrounding the tooth.
Unchecked tooth abscess may cause complications such as fistulae, facial disfigurement and falling teeth. Hence, it is important that tooth abscess should be treated as early as possible. Several treatment options for tooth abscess are:
• Use of antibiotics to kill the germ that caused infection
• Root canal treatment which involves drilling of the infected area, cleansing and resealing the infected tooth.
• Tooth extraction to clean the infected area

TMJ Disorders

TMJ, TMD or TMJD, temporomandibular disorder is a condition affecting the temporomandibular joint (TMJ) , which connects the mandible or the lower jaw to the temporal bone of the skull, which is located in front of the ear. The TMJ includes the muscles surrounding the jaw, blood vessels, bones and nerves. A person will have two TMJs, one located on each side of the jaw.
The TMJ mainly works to coordinate movements of the jaw, like chewing and biting. Any disorder in this area will therefore affect the flexibility of the jaw. You may notice pain while talking, yawning or chewing, and even while the jaw is at rest. TMJ disorder can cause intense pain, which can be intermittent, or can be constant and last for many years.
Symptoms of TMJ disorder
•The most common symptom of TMJ disorder is pain, with intense discomfort not just in the face and jaw joint, but also the neck and shoulders.
•You may experience an overstretched feeling in your joints, and may also suffer from muscle spasms.
•There is pain during jaw movements like talking or yawning.
•There can also be ear paining, tinnitus or ringing in the ears, or even hearing loss.
•You may even hear a clicking or popping sound when you move the joint. The sounds may be audible to other people also.
•There may be swelling of the face and mouth.
•There may be a shifting in the position of the teeth, or a change in the bite.
•You may find it hard to open the jaw fully, or the jaw may shift to one side after opening.
•You may experience trouble while swallowing.
•There could be nausea, headache or dizziness.
Diagnosis of TMJ disorder
Since TMJ is accompanied by an onset of pain we will gauge the intensity of pain by administering a “clench” test. If you experience pain in any one tooth or all teeth or the jaw when you bite down, dentist will diagnose it as TMJ. To confirm this diagnosis and to evaluate the position of the temporomandibular joint, your dentist will create mold impressions of your bite, and mount these on an articulator. Through this, your dentist can determine if there is a structural disorder inside the joint, or other factors like uneven teeth are affecting the joint.
Treatment of TMJ disorder
Very few TMJ cases are severe enough to need surgery. Most bite problems can be corrected through restoration or orthodontic treatment.
Dental appliances
If there is no structural disorder in the joint, but your dentist notices interferences that affect the bite, he may suggest correcting the problem using an appliance.
Occlusal equilibration
Occlusal equilibration is the most frequently used option to remove deflective interferences, and enable the jaw to close down properly. It involves the reshaping of the teeth surfaces that are involved in biting. Your dentist will examine the occlusion and the joints, before he recommends a particular treatment.
Mouth guards
The dentist may fit you with a plastic shield that acts like a mouth guard to protect your upper or lower teeth. This guard or splint can protect your teeth against teeth grinding when worn at night. If the splint causes pain, discontinue use.
Surgical treatment
If your dentist believes that your problem is caused by a structural disorder, and if your pain is not relieved through occlusal equilibration or the use of splints, then he will recommend an X-ray. Finally, he may recommend orthodontia, an intra-oral appliance or maxillofacial surgery, depending on the results of the scans. He will refer you to an oral surgeon or a maxillofacial surgeon. Surgery is performed under local anesthesia. Here, two needles are inserted into the temporomandibular joint, one connected to a syringe containing a cleansing solution, and the other acting as an exit for the fluid. This procedure is used to wash out the joint. In some cases, your surgeon will make use of a scalpel like tool to remove any tissue adhesions in the joint.
Another type of surgery to treat TMJ is orthroscopy, in which an incision is made at the temple to insert an endoscope into the area. Using images provided by the endoscope, your surgeon will remove adhesions, or reposition the disc.
Open joint surgery
Open joint surgery is the only option that allows access to any tumors, scarring or worsening bone structure.

First aid for TMJ
To treat intense pain before you meet with your dentist, try the following self help remedies.

•Apply hot and cold packs to the side of the face to lessen the pain. The pack should be applied for 10-minute durations.
•Avoid yawning or other extended jaw movements, and limit the amount of pressure you place on your jaw.
•Eat only soft foods, and avoid foods that require heavy chewing
•If you are under any dental treatment for tooth decay, continue with the treatment.
•Massages and biofeedback can also offer some relief from TMJ.
•Anti-inflammatory drugs, anti-anxiety drugs and anti depressants can provide relief from intense pain.
•Dental appliances like mouth guards can reduce teeth grinding which can enhance your bite, enabling your lower jaw to fit properly into the TMJ socket.
Remember that any TMJ treatment should only be provided by a dental specialist who is highly experienced in this area.

Alternative treatments for TMJ
Alternative treatments for TMJ include TENS (Transcutanaous Electrical Nerve Stimulation), radiowave therapy and ultrasound. Radiowave therapy and TNS work by sending radiowaves or low-intensity energy waves to the affected region to stimulate the flow of blood to the area. These alternative treatments do not work to treat the causes of TMJ, and can only be relied on for temporary relief.

Prevention of TMJ disorder
If you notice jaw pain occasionally, avoid eating hard foods, chewing gum or biting on hard objects. Support your lower jaw with your hand when you yawn. If you find yourself grinding your teeth or clenching your jaw at night, consult your dentist – he may be able to design a splint for you to protect your teeth.

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