TMJ Problems

TMJ Problems: Overview

Alternative Names: Temporomandibular Disorder, TMD.

"TMJ" stands for temporomandibular joint, or the jaw joint.  The TMJs are the small joints in front of each ear that attach the lower jaw (mandible) to the skull.  They allow you to perform such functions as opening and closing your mouth, chewing, speaking, swallowing, etc.

TMJ disorder is collection of symptoms which result when the chewing muscles and jaw joints do not work together correctly. TMJ diseases and disorders refer to a complex and poorly understood set of conditions, manifested by pain the the area of the jaw and associated muscles and limitations in the ability to make the normal movements of speech, facial expression, eating, chewing, and swallowing.  Conditions that routinely affect other joints in the body, such as arthritis and trauma, also affect the TM joint.

Incidence; Causes and Development

The National Institute of Dental and Craniofacial Research of the National Institutes of Health estimates that 10.8 million people in the United States suffer from TMJ problems at any given time.  Although both men and women experience TMJ problems, 90% of those seeking treatment are women in their childbearing years.

When normal relationships between the condyle, the disc, the fossa and the eminence are altered or distracted for whatever reason, the result is called "internal joint derangement".  Internal derangement includes cartilage disc displacements, clicking, popping, stretched or torn ligaments, perforated discs, infection/inflammation of the capsule or tissues, and adhesions of the cartilage to the socket of the jawbone.

Medical research has not yet defined all the causes of the various TMJ diseases/disorders.  Some patients report having TMJ symptoms following dental procedures, the insertion of a breathing tube prior to surgery, trauma, or oral habits such as clenching or grinding the teeth.  Conditions that occur in other joints in the body, such as arthritis, can also precipitate or aggravate TMJ pain and dysfunction.

Signs and Symptoms

TMJ symptoms vary widely from patient to patient and may wax and wane within an individual.  The most common symptoms experienced by people with TMJ diseases include:
  • facial pain
  • pain in the jaw joint and surrounding tissues, including the ear
  • jaw locking while open or closed
  • limited opening or inability to open the mouth comfortably
  • headaches
  • bite that feels uncomfortable, "off", or as if it is continually changing
  • neck, shoulder and back pain
  • swelling on the side of the face
When a problem is related to the muscle disorders, this is called myalgia/myofascial pain (pain from sore muscles).  Pain is usually due to persistent contraction of the muscle as they attempt to keep the lower jaw from excessive movement.  This causes pain to the jaw, face, head, neck and eventually translating to the shoulder, arm, back, hip, knee and foot.

Pain lasting for a week or less may not require medical/dental attention.  Popping and clicking sounds in the joint have been considered symptoms of a TMJ problem; however experts observe that many perfectly healthy joints make noise.  Jaw noises unaccompanied by pain or decreased mobility do not mean you have a TMJ problem.

Those with the symptoms listed above often report additional ones as well, such as ringing in the ears, ear pain, diminished hearing, dizziness or vertigo, and visual disturbances.  These symptoms may be a facet of TMJ disease or a different disease process occurring simultaneously.

People with TMJ implants are a subgroup of patients whose jaw problems led to surgery to replace all or part of the jaw joint.  The devices failed in a large number of these patients who then experienced serious complications requiring further treatments and often additional surgeries.  These patients have reported a variety of signs, symptoms and other medical problems, which may be related to their jaw implants and some of which may have occurred independently.  The TMJ Association lists these symptoms because TMJ implant patients frequently report them:

  • resorption or degeneration at the end of the jaw bone (the condyle) and the part of the skull where the jaw bone is inserted (the fossa); the mandibular, or jaw, bone described as "melting" or "soft"; skull penetration (holes in the skull)
  • disfigurement or deformity of the face
  • pain and dysfunction in the facial muscles
  • sleep disturbance
  • flu-like symptoms such as low-grade fever, malaise and fatigue
  • weakness and/or diminished muscle strength
  • lack of coordination
  • nausea with or without vomiting
  • visual disturbances, including reading problems, snow blindness, blurred vision, blindness
  • memory loss, confusion, inability to think clearly
  • seizures and/or blackouts
  • swollen lymph nodes/glands (e.g., neck, behind ears, under arms, groin)
  • abnormalities of the parotid glands (the salivary glands, located below and in front of each ear)
  • abnormal thyroid function
  • skin rashes, dry skin, itching, and sensitivity to the sun
  • Sjögren's Syndrome (dry eyes, dry mouth and dry mucous membranes)
  • changes in skin color and texture, such as hardening, thickening, or shining
  • allergies or similar sensitivities to chemicals and drugs
  • cold hands and feet
  • intolerance to heat and/or cold
  • dry, unproductive cough; chronic or episodic hoarseness
  • swallowing difficulties
  • chronic respiratory, urinary tract, pelvic, or gastrointestinal infections
  • benign tumors or granulomas in various parts of the body (e.g., breast tumors, fibrocystic breast disease, fibroid tumors)
One of the most common TMJ disorder symptoms is headache.  Over 90% of all chronic headaches, however painful, arise primarily from muscle contraction, most of which originate in the neck.  The pain of muscle contraction headache usually starts in the forehead, temples or back of the head and spreads over the neck and shoulders.  When neck muscles are dysfunctional or tight, this compresses the occipital nerves, one of the common nerves causing headaches.  When there is additional stress, mostly bad bite, that causes TMJ dysfunction, it makes them tighter, and compressing on nerves, blood vessels, and lymphatic channels within the joint spaces.  This combination of process can lead to the development of various kinds of headaches; migraine, tension-type, cluster-type.

Diagnosis and Tests

At this time, no formally established diagnostic criteria exist for TMJ diseases.

Treatment and Prevention

Non-surgical treatment can restore function of the TMJ (Tempero-mandibular joint) with surprising results.  Clinicians who have treated individuals with TMD (Tempero-mandibular dysfunction) have noted that related conditions such as tinnitus have been improved and, in many cases, eliminated.  Non-surgical treatment is appropriate in cases where the symptoms are related to mild joint damage, muscle hyperactivity and/or dental-skeletal malalignments.

These interventions include application of heat and cold, prolotherapy, injections of a local anesthetic into muscle trigger points, passive and active jaw exercises, medications such as muscle relaxants and anti-inflammatories, multivitamins, neuromuscular orthotics, biofeedback and acupuncture, transcutaneous electrical neural stimulation, coronoplasty, and cortisone injections.

Sometimes TMJ problems resolve over time with patients taking mild pain-relieving drugs and using heat, cold or other palliative measures.  At present, there are more than 50 treatments in use ranging from very conservative, reversible therapies to more aggressive, invasive approaches.  None of the surgical treatments for severe cases have been proven effective in long-term controlled clinical trials.

The Resultant Force Vector Technique is able to reduce abnormal muscle tension and to restore balance within the body by correcting bite and establishing physiological function of TMJ.  Through this technique it is claimed that stress-related headaches have been relieved 90-95% of the time in the absence of complicating medical problems.  Those suffering from weekly or daily headaches, who are also taking medications without knowing when the headaches will cease, should evaluate such alternatives.

Dr. Wesley Shankland, Past President of the American Academy of Craniofacial Pain recommends three criteria be satisfied before TM Joint surgery is tried.  The criteria are:

  • All conservative treatment has failed.  If splint therapy has failed once, it should be repeated, with a different splint design, or by a different doctor.
  • There is a demonstrable physical or structural explanation for the patient's complaints.  A physical problem can be seen with an MRI, X-rays, or with dye injections into the joint (arthograms).  Make certain that this is not an exploratory surgery or that the surgeon "thinks" this surgery will help.
  • The Patient must be suffering so much that they must take strong pain medication, and their life-style is greatly altered.  In other words, the patient must be desperate and at the "end of their rope" before surgery is attempted.
Don't permit the doctor to proceed with any invasive or irreversible procedure too soon, and insist on a referral to other practitioners who are trained to listen to symptoms, observe signs, and place these findings into neat packages to determine a diagnosis and treatment into a conservative non-invasive modality.

Prognosis

Various surgical methods and techniques have been developed for TMJ surgery since the 1980s.  Surgery was one of the most popular treatment modalities for patients whose symptoms could not be relieved by splint therapy or other conservative treatments.

Despite some patients experiencing symptomatic relief, others have suffered more after surgery.  The procedure was irreversible and there was nothing much to do except medicate to control the pain.  Because of the severity of pain and the side-effects of drugs, both patients and doctors struggled.

These days, better non-surgical techniques and drugs have been developed, and both surgeons and non-surgeons consider surgery as the last treatment modality option.

Post-surgical symptoms are categorized as "chronic pain symptoms" and must be treated/managed accordingly.

Signs, symptoms & indicators of TMJ Problems:

Symptoms - Head - Mouth/Oral

Non-replacement of missing teeth may be a sign or symptom of TMJ Problems Partial replacement/non-replacement of missing teeth

Missing teeth should be replaced in order to prevent shifting and therefore misalignment of the remaining teeth, which can lead to TMJ.

Conditions that suggest TMJ Problems:

Metabolic

Tinnitus often suggests TMJ Problems Tinnitus

A study of twenty patients with tinnitus found that ten tested positive for TMJ dysfunction in all diagnostic tests used, and nine more tested positive to one or more of the diagnostic procedures.  Only one patient of the twenty had no positive evidence of any jaw joint dysfunction.  Dr. Morgan's findings were published in The Journal of Craniomandibular Practice.  ["Tinnitus of TMJ Origin: A Preliminary Report," Vol.10, No.2]

Another research project was headed by Richard L.  Goode, MD, professor of ENT and Head and Neck surgery at Stanford University's School of Medicine.  Drs Morgan and Goode were able to establish the mechanical connection between the ossicles in the middle ear and the capsule and disk of the TMJ.  ["The TMJ-Ear Connection", Journal of Craniomandibular Practice, Vol.  13, No.1).]

You may get an idea if the tinnitus is connected to your TMJ in some way, by:

  • Clenching your teeth – does it change the tinnitus in some way? (Get louder/softer, pitch change)
  • Pushing in hard on the jaw with your palm.  Does the tinnitus change?
  • Pushing in hard on the forehead with your hand.  Resist with the head.  Any changes?
As many as 50% of people using these techniques find a change in their tinnitus and a TMJ correlation they had not known about.

Symptoms - Skeletal

Risk factors for TMJ Problems:

Dental

Tooth Loss may increase risk of TMJ Problems Tooth Loss

Dental conditions such as a high filling or displaced teeth due to tooth loss can cause TMJ.  When teeth shift due to earlier loss of teeth, this can result in tooth/jaw misalignment.

Bruxism (Clenching/Grinding Teeth) may increase risk of TMJ Problems Bruxism (Clenching/Grinding Teeth)

Although the link is not clear, stresses on the jaw caused by bruxism can lead to TMJ dysfunction.  The muscles that stabilize the joint become fatigued from frequent clenching and/or grinding of teeth.

Immunity

Chronic Fatigue / Fibromyalgia Syndrome may increase risk of TMJ Problems Chronic Fatigue / Fibromyalgia Syndrome

TMJ disorders occur more often among those with CFS.

Musculo-Skeletal

Rheumatoid Arthritis often increases risk of TMJ Problems Rheumatoid Arthritis

If the TMJ is affected by rheumatoid arthritis, it is usually one of the last joints involved.  RA affects the TMJ in almost 20% of cases.  Pain, swelling, and limited movement are the most common symptoms.

Osteoarthritis may increase risk of TMJ Problems Osteoarthritis

The TMJ may be affected by osteoarthritis, usually in those over 50 years old.  Symptoms include stiffness, grating, or mild pain.  Both sides of the jaw are usually involved.

Recommendations for TMJ Problems:

Mineral

Surgery/Invasive

Prolotherapy is highly recommended for TMJ Problems Prolotherapy

Prolotherapy regrows tendons and ligaments to strengthen and stabilize overly mobile joints such as the TMJ.

KEY

Weak or unproven link: may be a sign or symptom of; may increase risk of
Weak or unproven link:
may be a sign or symptom of; may increase risk of
Strong or generally accepted link: often suggests; often increases risk of
Strong or generally accepted link:
often suggests; often increases risk of
Definite or direct link: strongly suggests
Definite or direct link:
strongly suggests
May be useful: may help with
May be useful:
may help with
Very useful: is highly recommended for
Very useful:
is highly recommended for