Biting Comments

There are millions of Americans who have at least periodic jaw pain. Various names have been given to this phenomenon including: TMJ Syndrome, TMD (Temporomandibular Disorders), or I’ve just heard folks say, “I’ve got TMJ”. In any case, TMD is not just one disorder, but a group of conditions, often painful, that affect the jaw joint and the muscles that control chewing. About twice as many women as men seek treatment for this disorder, but there’s no physiologic reason why the fairer sex should be preferentially burdened. Perhaps, the statistic simply reflects the pervasive doctor-avoidance which typifies men–regardless of the health issue. In any case, Jaw Pain is very common, and deserves some attention in this week’s Insight. Let’s chew on the meat of the subject below.

To understand how things can go wrong, we need to examine the joint itself. The temporomandibular joint connects the lower jaw (called the mandible) to the temporal bone at the side of the head. You can feel the joint by placing your finger below your ear and opening and closing your mouth. Because of its flexibility, the joint allows smooth motion up and down and side to side, enabling us to talk, chew, and yawn. A shock absorbing disc and a network of muscles complete the anatomy of the temporomandibular joint. Like many other joints in the body, initially the TMJ simply hinges open. However, it then glides forward and down to complete a full motion; no other joint in the body makes such a movement. Additionally, remember that our jaw bone has both right and left sided joints which are connected and must move simultaneously to allow talking, chewing, etc. When one considers the complexity of TMJ movement, it’s understandable why problems can occur. Ideally, the muscles, teeth, and jaw joints should function in harmony. When they don’t, the multifaceted TMJ Syndrome can result. Are you salivating for more? Then, let’s jaw a little about possible causes.

Though there appears to be great disagreement on both diagnosis and management guidelines, researchers do seem to agree that temporomandibular disorders fall into three main categories:
1) Myofascial pain–where the discomfort or pain seems to be generated in the muscles, ligaments, and soft tissues of the neck, face, and shoulders which are involved in jaw function
2) Internal Derangement of the joint–where discomfort is generated by dislocation, displaced disc, and/or injury to the bone surfaces that articulate in the TMJ
3) Degenerative joint disease–where defined forms of arthritis (such as osteoarthritis or rheumatoid arthritis) erode normal, healthy joint tissue and generate the subsequent pain of arthritis.

A person may have one or more of the above conditions simultaneously. And, of course, the treatment recommendations can vary significantly based on the etiology of TMJ Syndrome. Symptoms can range from pain (especially in the chewing muscles and/or jaw joint), to limited movement or jaw locking, radiating pain into face, neck, or shoulders, painful clicking, popping, or grating sounds when opening mouth, or a sudden major change in the way upper and lower teeth fit together. Tinnitus, earaches, and dizziness can also be part of the syndrome. One therapist comments that a great deal of confusion arises from the fact that temporomandibular disorders are medical problems (or perhaps more appropriately orthopedic problems) that require a dental solution.

In any case, know that for most people, the pain of TMJ Syndrome is usually transient and can be treated conservatively. There are no standardized tests, so history and physical examination generally make the diagnosis. Sometimes x-rays, including MRIs and arthrograms are indicated in the evaluation. Only a very small percentage of people develop long-term symptoms, and in such cases, it appears that a person is wise to seek several opinions about therapeutic options. . .especially if surgery is recommended. Are you chomping at the bit to hear about common treatments? Then, let’s munch on additional information.

Self care practices, such as eating soft foods, applying heat or ice packs, and avoiding extreme jaw movements (such as wide yawning, loud singing, and gum chewing) can help to ease TMD symptoms. Biofeedback and relaxation techniques are helpful to some folks–esp. when tense facial and jaw muscles seem to be a major component. Jaw clenching and teeth grinding can generate significant TMJ pain, and folks with these propensities can benefit from such therapies. Physical therapy which focuses on gentle muscle stretching and relaxing exercises can also be helpful. Chiropractic and acupuncture may be considered as well. Sometimes injecting the painful ‘trigger points’ of muscles with parenteral pain medications can provide at least short term relief. And, short-term use of muscle relaxers and anti-inflammatory drugs can help to ease the acutely painful stages as well.

The above therapies concentrate primarily on the SYMPTOMS of TMD. When a true TMJ problem exists, correcting the physiology may ultimately be of greater benefit. If a therapy can help to promote the most ‘naturally correct’ position for the jaw joint, muscles, and teeth to work together, the temporomandibular joint will operate more efficiently and with the least trauma being passed to the joint by teeth and muscles. An oral appliance, also called a splint or bite plate might be recommended. It’s basically a plastic guard that fits over the upper or lower teeth as is intended to place the joint in a neutral/nonstressed position. Short term use of splints seems to be the general recommendation, because permanent changes in one’s bite are not desirable in most cases. However, if symptoms diminish while a person is wearing a splint, more definitive long term treatments might be recommended. Let’s consider some additional therapies of mastication management with this thought in mind.

Transition from splint use to a physiologically neutral bite can involve any one or combination of: 1) Reshaping teeth to allow joint function with acceptable tooth fit 2) Restorative dentistry such as placement of crowns, bridges, partials, etc. designed to facilitate healthy joint function 3) Orthodontic treatment to move teeth into a healthier functioning position 4) Jaw surgery to reposition the upper and lower jaw structures for better functional stability. Obviously, this is the most invasive of the choices, and would be considered only when the symptoms are severe and unrelenting, and all other therapeutic options have failed. Jaw joint implants are available, but apparently there have been some serious long-term medical problems from such devices, and the FDA has tightened restrictions on their usage. Once again, most therapies begin with conservative, non-invasive, and reversible treatments.

For many people, discomfort from TMD will eventually go away whether the person is treated or not–through simple self-care practices. Treatments that cause permanent changes in the bite or jaw should be avoided if possible. However, if all other options have failed, consider such therapy after several reliable opinions have been obtained. The irreversible therapies listed in the above paragraph continue to be controversial in terms of their benefit, and in fact can make the symptoms worse if not performed for clear cut reasons by a skilled dentist or oral surgeon. Nibble on the conservative options before you take a big bite into more complicated treatments. Run from a Dentist or Oral Surgeon who wants you to swallow the notion of surgery right off the bat.

Stephen L. Hines, M.D.
October 2001