TMD (temporomandibular joint disorder) occurs when there is dysfunction with inflammation within a mass of associated muscles of the head and neck where the muscles, tendons, ligaments, nerves and supportive structures are associated with the temporomandibular joint. Of all medical and dental conditions, TMD is probably the most misdiagnosed. Few physicians, including dentists, have a comprehensive understanding and perspective in the diagnosis and treatment of TMD. TMD has many symptoms that overlap each other and mimic other conditions like medical neurological dysfunction including headaches, tinnitus, ear pain and congestion.
TMD misdiagnosis is the rule rather than the exception. Confused patients are led from one specialist to another, depending on the type of pain and problems experienced. Neck and head pain finds the chiropractor, acupuncturist or physical therapist. Jaw pain finds the oral surgeon who looks at conditions from a surgical perspective and at most makes a night guard that doesn’t work. Ear, sinus, or throat problems are referred to the ear, nose, and throat (ENT) specialists where, in many cases, the patient is told that their ears are okay and nothing further can be done. Patients with headaches see a neurologist who indicates the need for an MRI to check for a tumor and prescribe muscle relaxant medication to deal with the headache, and with limitations of jaw movement, patients are led to the orthopedist, all unable to help them in the long run.
As the confused patients are constantly told that there seems to be no organic basis for their pain, that the cause is psychogenic, their anxiety increases. Or, many times these patients are improperly treated with medication and in some cases are recommended unnecessary surgery for the particular symptom, now being recognized as a medical problem. When patients fail to find the reasons for their debilitating problems, they suspect the worst: an undiagnosed tumor.
Tinnitus, Dizziness, Light Headedness, Imbalance, Ear Congestion and the TMJ Connection
Major sources of patients coming to my office are referrals by ENT physicians. The ENT doctor in many cases tells the patient that their ears are normal, and maybe they should see a TMJ doctor for further evaluation.
Often the patient with TMJ/CMD (craniomandibular dysfunction) complains of ringing in their ears, or vertigo, lightheadedness, stuffiness or imbalance or a feeling of fullness or pressure in the ears. The tensor tympani and tensor levi palatini outside the inner ear canal tighten up whenever the jaw-closing muscles next to them are under stress, i.e., whenever the jaw is clenched. The reason is that the same nerve (the trigeminal 5th cranial nerve) feeds all of the jaw muscles as well as these two important ear muscles. Clinically we have found that ear ringing, dizziness, light headedness, or imbalance occurs in over 50% of the patients who present with ear pain, congestion, fullness, hearing loss, etc. After insertion of a deprogramming orthotic, and usually within 3 months, tinnitus associated with TMD is generally relieved.
Many of our patients have associated jaw movements, or pressure on the TM Joint with all of the ear symptoms listed above.
Visual Disturbance and the TMJ Connection
Studies (Fisioter. Nov. 2008 out/dez; 21(4):63-70) show the presence of visual disturbance in over 66% of TMD cases, and noted that a disturbance of vision could also influence the balance, illustrating how everything is connected.
Soreness, Tightness, Muscle Fatigue of the Head, Neck and Shoulders and the TMJ Connection
The tightening of the muscles surrounding the TMJ can cause pain, with the trigger point connection of muscles transferring the pain back and forth from head to neck and shoulders. The primary source of muscle spasms may be the jaw joint referring pain to the satellite region of the neck and shoulders.
Or, the primary source of pain may be the neck and shoulders with satellite connection to the jaw joint region. This is usually considered indirect trauma common with whiplash due to a car accident or a fall. Often, we see patients who seek treatment for neck and shoulder problems who do not receive a proper diagnosis for their jaw issues, and vice versa. Successful head, neck and shoulder pain treatments must take into account all of the structures of the head and neck. A major complaint is muscle soreness or fatigue in the head and neck areas.
Sleep Disruption and the TMJ Connection
Patients report they’re twisting and turning during sleep. After a period of sleep you will open your eyes and roll to a different position. You will repeat this a few times that evening. It may not be a constant nightly occurrence, and often there is no weekly pattern. While sleeping during those restless moments, you are clenching your teeth. And if you happen to be wearing a full mouth night guard made by your dentist, the night guard will probably make things worse by exasperating the clenching. You may wake up with a headache and/or have tired and strained head and neck muscles. Many patients even complain of tingling sensations down to their fingertips upon awaking.
Clenching of Upper and Lower Back Teeth and the TMJ Connection
Clenching during sleep is key to control. Temporal muscle excitement must be at zero level during sleep. The nine hundred pounds of posterior clenching pressure caused by the temporal muscle must be eliminated. Only our orthotic can eliminate the clenching by inactivating the temporal muscle during sleep. In most situations, the patient is not aware of back teeth clenching during sleep. However, the patient might be aware of something going wrong at night as they may wake up with jaw pain or a headache, or at best just have a restless sleep.
If the patient clenches back teeth during the daytime as well as at night, and has episodes of migraines, it would be recommended that the patient wear the muscle orthotic during the day for a period of time. The wearing of the orthotic during the day is needed to counter the “anticipated clench” that occurs during the day (daytime temporal excitement) where the temporal muscle remains in an excitable stage even though the patient is not applying the extraordinary clenching pressures that exist during sleep. The orthotic worn during the day eliminates daytime temporal muscle action and trigeminal nerve activity, the main source for migraine.
Grinding of your teeth may indicate you clench, and although it may wear your teeth down, it will not affect the jaw joint. The reason is that grinding is the intermittent pressure of teeth hitting each other. It is not constant pressure like that which clenching creates. Clenching pressure between back teeth can reach up to 900 pounds of pressure.
Sinus Pain and Congestion and the TMJ Connection
Chronic tension may affect the whole head and the sinus area will not be an exception from this rule. There are four large sinuses: two inside the cheekbones (the maxillary sinuses) and two above the eyes (the frontal sinuses). There are also smaller sinuses (ethmoidal and sphenoidal sinuses) located between the larger ones. Sinus bone and the nasal septum is thin bone. There is an elevator (clenching) muscle attachment to this area with common 5th cranial nerve involvement. Aggravating the porous thin bone and attached tissue with spastic inflamed strong muscles can lead to pain and congestion.
Migraines and/or Tension Headaches and the TMJ Connection
The main source of TMD head pain is the hyperactivity of the trigeminal nerve and the temporal muscle so close to the cortex membrane of the brain. I find clenching of the back teeth at 600 to 900 pounds of crunching pressure, whether day or night, so prevalent with almost all headache cases I treat. Almost all migraine conditions accompany hyperactivity of the temporal tendon, lateral pterygoid, and medial pterygoid muscles bi-laterally. I just don’t understand why very few doctors palpate those muscles upon patient examination. It’s a dead giveaway to TMD migraine/tension headache.
Jaw Clicking and Popping, or Lock on Opening Lower Jaw and the TMJ Connection
The mandibular jaw bone (lower) rotates under the maxillary bone (upper) as it opens and closes. There is a thick connective tissue pad (articular disc) that sits between the two bones preventing them from damaging each other. If you hear clicking, popping bubbling or grating noises, your lower jaw at that point is attempting to get onto the articular disk so as not to have both upper and lower bones directly abrade each other. Example: if you hear the click halfway open, then from the closed position to that half way open position, you were having bone possibly touching bone as the jaw was opening. If the maxillary (upper) bone at that point is not touching the condyle head of the lower jaw, at best there is only thin tissue (retrodiscal) between the two bones. The click or pop sound is the attempt of the articular disc to get between the two bones for protection. Pain doesn’t necessarily occur, however this joint disruption with clicking, bubbling or grating sounds indicates damage is being done to the complex of muscles, tendon, nerve, and articular disc tissue.
When your lower jaw locks up or appears to freeze in an open or closed position, the lower jaw (mandible) is stuck either in front of or in back of the articular disc. An open lock of the jaw indicates that the lower mandible is stuck in front of the disc and cannot close. A closed lock is where your jaw is closed and you cannot open your jaw, indicating that the mandibular head (condyle) is stuck behind the articular disc. Both conditions indicate serious disruption of the jaw joints.