THE MANY FACES OF TMD

Chronic recurrent headaches are a common finding in millions of Americans. In addition, many of these people suffer from chronic facial, neck, and shoulder pain. Troublesome ear symptoms including congestion, ringing, buzzing and pain are frequently encountered for no identifiable reason. Often times, these sufferers have been told it was "all in their mind or all due to stress". After months, if not years, of unsuccessful searching for answers, they have learned to live with the pain, usually with the aid of over the counter drugs like aspirin, when they were effective. Today it is known that a family of conditions termed TMD (Temporomandibular Disorders) accounts for a large number of these painful and troublesome symptoms. The above types of pains are symptoms of the problem--not the problem itself. Correcting the underlying problem rather than simply treating the symptoms is at the heart of TMD treatment. Today with new knowledge and technology, we are able to diagnose and treat TMD problems which had previously been overlooked or improperly diagnosed. Additionally, other informed members of the health care community are becoming more aware of these problems and are recommending treatment by referring patients to dentists knowledgeable in TMD treatment.

 

Jaw problems can trigger problems with the
muscles in the face and neck,
causing head, neck, and facial pain.

 

WHAT IS TMD?

The term TMD is used to describe a family of disorders which involve the jaw complex. This includes the jaws, muscles, jaw joints, ligaments, tendons and nerves. Problems frequently develop within this complex and may affect any or all of these components. When this occurs a variety of pain symptoms frequently result. These include headaches, facial and ear pain. Patients may also experience other symptoms including buzzing, ringing, congestion and pain of the ear as well as bouts of dizziness, clicking or locking of the jaw, making it difficult to open the mouth. Sufferers with TMD usually experience one or more of these symptoms. Due to the interrelationship of the jaw and neck muscles, many people suffering from TMD will also display pain and tightness in the neck and shoulder muscles. Because of the variety of anatomical structures and therefore variety of problems which may be involved with TMD, a thorough examination, by a doctor with advanced training in TMD, is essential to a proper diagnosis. Once accomplished, treatment can be planned frequently alleviating months or years of suffering and often preventing continued permanent deterioration.

 

HOW COMMON IS TMD?

A recently released guide to dental health from the American Dental Association stated that roughly 20 percent of all Americans suffer from TMD. This statistic would indicate that as many as one in five Americans suffer from this problem. In addition, it has been estimated that 40% of all chronic pain occurs in the head, face and neck. People with TMD frequently suffer from headaches, facial or neck pain as well as various ear symptoms including ringing and buzzing, congestion, pain and partial hearing loss. Temporomandibular Disorders have frequently been called the "great imposter". Because of the wide variety of symptoms produced. Because of its genius for disguise, this condition is frequently mistaken for neuritis, neuralgia, migraines, tension headaches, various ear disorders and stress related problems. Because it is possible for these types of disorders to produce symptoms similar to TMD they should always be adequately evaluated by your medical physician. If, however, no specific problem or diagnosis can be given to the problem, a TMD should always be considered as the possible cause of the problem.

 

TMD-THE CLICKING JAW

Temporomamdibular Disorders are categorized into two broad divisions of problems. The first are those that directly involve the jaw joint and the second involve the associated structures of the jaw including the muscles, ligaments, tendons and nerves. The jaw joint (TMJ) is a ball and socket joint that connects the lower jaw to the upper and is located directly in front of the ear. As with any joint there are a variety of orthopedic disorders that can effect this joint. A common problem associated with the joint is a slipped disc. Between the ball and socket is a small cushion called the disc. This disc, among other things, is designed to act as a shock absorber and keep the bones from rubbing against each other when moving the jaw. This disc can slip out of position and when it does popping and clicking of the jaw is noted with movement. The cause may be related to injuries, loss and non-replacement or improper replacement of back teeth as well as developmental disorders of the jaws or facial bones. This condition frequently produces headaches, facial and ear pain. In addition, congestion, buzzing, ringing and pain in the ear may result. If left untreated, the condition may lead to "locking" of the jaw, degeneration of the joint or both.

  

Normal TMJ
A: Articular Fossa (socket)
B. Mandibular Condyle (ball)
C: Articular Disc 

 

Clicking Jaw. Disc is displaced forward of condyle, clicking on and off of the condyle with opening and closing.

 

TMD-THE LOCKED JAW

If the clicking joint is not treated, it may lead to "locking" of the jaw. In this condition, the disc becomes deformed or wedged between the ball and socket and the sufferer experiences a limitation of jaw movement often with a feeling of "catching or locking" in the joint with movement. Headaches and jaw or facial pain are usually seen with these patients. In addition, many experience various ear symptoms. If treated early, most patients can be treated without surgery but if allowed to progress, degenerative changes and surgery may result.

Closed Lock. Disc is displaced and does not reduce
during opening. There is limitation of motion and often pain.

 

TMD: PAIN IN THE NECK
MAY BE RELATED TO THE JAW

A common symptom associated with TMD is neck pain. When most people suffer from pain in the neck, they do not associate this with a problem related to their jaws. At first glance it would appear as though the jaws, temporomandibular joints (TMJ), and neck structures would be unrelated. Upon closer evaluation however, it becomes obvious how neck pain can frequently be associated with TMD. A common finding with TMD are stresses in the muscles that move the jaws. These stresses may take the form of tightness or spasm of the jaw muscles. When stresses are introduced into the jaw muscles, these stresses can be transferred to other muscles of the head and neck. The head is positioned on the spinal column much like a large ball precariously balanced on the end of a pole. The head is held in place and stabilized through an intricate system of muscles and tendons. When the muscles in the jaws are stressed or contracted, their reciprocal muscles in the back of the head or in the neck must also contract in order to maintain the proper relationship of the head on the spinal column. These muscles in the back of the neck and shoulders then become very tight and painful. In addition to this type of relationship between the jaw and the neck, it is well established that an improper bite due to developmental problems or loss of teeth which has allowed the jaws or "bite" to collapse has a direct relationship on the head posture as it relates to the spinal column of the neck. With these types of jaw related problems, the head may be forced to adjust to a new postural position on the spinal column and as a result, set up tensions within the neck musculature which can also result in significant pain in the neck and shoulder regions.

 

TMD: EAR SYMPTOMS AND THE JAW

Various ear symptoms including ear pain, congestion, buzzing, ringing, partial hearing loss, as well as dizziness, have been associated with temporomandibular joint or TMJ disorders. Aside from the close proximity of the TMJ to the ear, there are several mechanisms which are currently believed to be responsible for the ear symptoms frequently seen with these types of problems. It is known, for example, that several muscles which are directly associated with the ear, receive their nerve supply from the same nerve that supplies the muscles of the jaw. It is not difficult to see that when muscle problems resulting from TMD are present, a misdirection of signals might very well occur, causing change in the muscles that are associated with the ear and causing various ear symptoms to occur. In addition there exists a ligament (sometimes called Pinto's ligament) that is attached at one end to the TMJ while the other end is attached to one of the small bones found in the middle ear. It is felt by some that this may be responsible for many ear symptoms associated with TMD due to stress transferred from the TMJ to the middle ear. A term - the otomandibular syndrome - has been coined by Harold Arlan, M.D., Assistant Clinical Professor of Otolaryngology Surgery from the College of Medicine and Dentistry of New Jersey and Rudkers Medical School. According to Dr. Arlan, a patient with "otomandibular syndrome:" complains of pain in and around the ear, fullness in the ear, hearing loss, tinnitus, and a loss of equilibrium. Dr. Arlan states that the patient may have one or many of these symptoms and that no pathology in an evaluation of the ear can be found. Dr. Arlan states, however, that in these patients, spasm of the jaw muscles is always seen. From this information, it is easy to understand how TMJ problems may produce various types of ear symptoms. It is always suggested that when a patient is experiencing symptoms related to the ear, that they be thoroughly evaluated by their physician for possible pathology related to the ear. If, however, no disorders can be found, an evaluation for a possible TMD should be completed.

 

TMD:THE MIGRAINE MIMIC

Severe and chronic headaches are a trademark of TMD. These headaches may range from dull to sever pain that may be of migrainous proportions. A common TMD is a condition called "Temporal Tendinitis" frequently referred to as the "migraine mimic" because it produces migraine like headaches. The temporalis muscle is a jaw muscle. It attaches at one end to the head along the side. If you place a finger on the temple and tightly squeeze the teeth together, you can feel the muscle bulge. It's other end finds its attachment to the lower jaw through a structure called the temporal tendon. When the tendon becomes inflamed, a condition termed "Temporal Tendinitis" (insertion tendenosis of the temporalis muscle) results. This condition refers pain to a variety of areas including the temple producing headaches in the side of the head, the jaw joint causing joint pain, the ear causing earaches and the pain in the jaw or side of the face. Many causes have been implicated for producing the problem including trauma, such as blow to the jaw, whiplash injuries, grinding of the teeth, muscle spasm, jaw joint disorders, tension and bite problems. Treatment is readily available and in the majority of patients is highly successful. The result is rapid relief of pain even when it may have been present for a prolonged period. Because the area of TMD is relatively new, practitioners involved with treatment of headache pain may not always be totally familiar with this condition and the diagnosis of migraine may be mistakenly made.

 

TMD: MYOFASCIAL PAIN DYSFUNCTION

Myofascial pain dysfunction refers to a painful condition which effects muscles. This problem was first recognized by Dr. Janet Travell, personal White House physician to former President Kennedy. She found that this condition can effect any muscle of the body and is very common in the jaw, face, and neck areas. When the condition is present, "trigger points" form within the muscle. These points produce localized pain in the area and can also refer pain to other areas of the body. When the jaw and TMJ's (jaw joints) are misaligned, the muscles become stressed. Painful muscle spasm and trigger points are the result. As this occurs, jaw pain, facial pain and headaches are the outcome. Because the jaw and neck muscles work closely together, this ultimately produces increased stress in the neck and shoulder muscles. The result is spasm and/or trigger points within these structures. The consequence is pain in the neck and shoulder muscles as well. This may be confusing to the patient suffering because the location of the pain may not be where the actual problem is located. In addition to pain, "trigger points" often produce limitation of movement causing a "stiffness" of the muscle. Until the TMD is corrected, needless suffering is the result.

 

TMD: ERNEST SYNDROME

Ernest Syndrome is a condition which is caused by an inflammation of a ligament that attaches to the jaw and produces seven areas of pain referral to the head and neck. The stylomandibular ligament grows from a bone under the floor of the ear and attaches to the back of the lower jaw approximately one half inch below the ear lobe. Its purpose is to limit the movement of the jaw and keep it from opening too wide or moving too far forward. When the Ernest Syndrome is present, the sufferer may experience one or more of the following types of pain: temple pain (often thought of as headache in the side of the head), ear pain and pressure, eye pain, pain along the cheekbone, pain in the jaw joint, throat pain (throat may feel like it is irritated in swallowing) and lower jaw pain which may feel like tooth pain. Diagnosing this problem is uncomplicated and once treated, pain can be relieved that has often existed for long periods of time.

 

TMD: OCCIPITAL MYALGIA-NEURALGIA SYNDROME

Occipital Myalgia-Neuralgia Syndrome is a frequent finding with people suffering chronic recurrent headaches. Myalgia refers to muscle pain while neuralgia denotes pain of a nerve. In this syndrome, pain emanates at the base of the skull. The person will complain of headache in this region or may describe it as pain in the upper neck. The muscle component radiates from the attachment of the neck muscle to the base of the skull while the nerve aspect is derived from the occipital nerves that course through this area. In addition to pain at the base of the skull, people with this problem will frequently have pain over the eye described as a forehead headache and often experience pain behind the eye. Additionally, the sufferer will experience temporal headache in many cases. Although the pain may be severe, treatment is normally uncomplicated and highly successful.

 

TRIGEMINAL NERVE PAIN (NEURALGIA)

The Trigeminal nerve also called the fifth cranial nerve is the major nerve carrying sensation to the head. As such, it can be responsible for pain, involving the head, face and jaws. In Trigeminal Neuralgia, pain can occur along any branch of this nerve. As a result, the sufferer may experience pain in any area supplied by this nerve. This may occur over the eyes or in cheek, jaw, face and around the ear. Also, the individual may complain of headache type pain in the temples or forehead. In addition, the sufferer may experience toothache like pain often seeking dental treatment only to find that the suspected tooth or teeth are normal. The patient may have root canal therapy or worse - extraction of the suspected tooth only to find that the pain persists or moves to an adjacent area. The quality of the pain may range from a dull aching sensation to a deep boring type of pain which at times may be incapacitating. Some patients experience severe episodes of electrical shock like pain often precipitated by contact with a certain area on the face. Numerous treatments have proven successful in reducing or eliminating the pain.

 

EAGLE'S SYNDROME

Eagle's Syndrome is characterized by pain in the throat with referral of pain often being felt in the ear. The patient may have a feeling of a foreign body in the throat and difficulty and/or pain with swallowing. In addition pain in throat with turning of the head may occur.

The disorder is caused by an elongation of the styloid process. The styloid process is a small projection of bone that originates from the base of the skull and is the attachment of several muscles and ligaments that run into to the throat and tongue. In addition the Stylohyoid ligament may become calcified producing the same problem. This ligament runs between the process and the hyoid bone which is a bone in the front of the throat and is the attachment of a number of throat muscles.

When present this condition produces pain in the throat with pressure on the side of the throat or the side of the neck just below the lower jaw. It can typically be visualized with a standard dental panoramic radiograph. Treatment is normally surgical in nature and is usually not complicated.