What is TMD? And Do You Have It?
Health problems and the pain associated with disorders of the jaw joint (the temporomandibular joint) may seem to be mysterious and unexplainable to you, but there are growing numbers of health care practitioners who are qualified to diagnose and treat Temporomandibular Joint Disorders (TMD). While no amount of printed information can replace a complete examination by a qualified practitioner, it is often comforting to have some of your questions answered before taking that major step and making an appointment to consult "an expert".
Some patients live with TMD for years before it becomes painful enough to cause them to seek help. Others contract the problem suddenly - usually by some trauma or blow to the head, face and/or neck region. But both types of patient can have very similar symptoms.
Even though a headache can be a sign of many kinds of health problems, frequent headaches are the most common complaints of TMD sufferers. Other common complaints can include clicking or popping jaw joints, pain when chewing or yawning, grinding or clenching your teeth, neck/shoulder pain, worn teeth, your teeth do not touch when you bite, "stiffness" in your jaw joints that makes it difficult to open or to close your mouth. Again, only a qualified health care practitioner can tell you for certain if any of these problems are a direct result of TMD.
Methods for successful diagnosis and treatment of TMD vary from patient to patient and from office to office. Some problems may require a "team-approach" which means several different health care practitioners may be working with you concurrently to help alleviate your problem. Treatment can take time and even the amount of time varies from patient to patient. Sometimes it even takes time to get an appointment with a qualified health care practitioner.
TAKE A SELF EVALUATION QUIZ
Jot down your answers to the following questions to find out if you have the symptoms of periodontal disease.
- Do you have frequent headaches?
- Do you hear popping, clicking or cracking sounds when you chew?
- Do you hear a grating sound (like crumpling of newspaper) when you chew?
- Do you have stuffiness, pressure or blockage in your ears?
- Do you hear a ringing or buzzing sound in either or both of your ears?
- Do you experience dizziness frequently?
- Do your jaws feel like they "catch?"
- Do your jaws feel tight, difficult to open?
- Does it appear that you can't open your mouth as wide as you used to?
- Does you tongue go between your teeth or do you bite on your tongue to separate your teeth?
- Do your teeth ache?
- Are your teeth sensitive, especially to cold temperatures?
- Do you wake with sore facial muscles?
- Do you clench or grind your teeth during movements of frustration or concentration?
- Do you grind your teeth at night?
- Do your ears hurt?
- Does it hurt to move your jaw sideways?
- Do your neck, back of your head, or shoulder hurt?
- Have you been hit in the jaw?
- Have you been put to sleep for surgery?
- Have you seen a neurologist, psychologist or psychiatrist for unexplained head or neck pain?
- Do your jaws ache after eating?
- Are you under a lot of stress?
- Have you been told that you might have TMJ?
Don't let TMJ disorder take away your smile. If you answered yes to any of these questions, consult a specialist right away! Here are a few suggestions you might follow to help if there will be a lapse of time before you can get an examination appointment:
- Ice packs are excellent in reducing pain and muscle spasm. Place ice packs over the temple area and side of the face for ten minutes, three or four times a day. Ice packs may be repeated hourly if you are in severe pain.
- Place yourself on a soft (not liquid) diet. Eat a good balanced diet consisting of foods like cooked whole grains, beans, vegetables, eggs, fish, cheese, ground meats, fruit, etc. Avoid foods like salads, apples, tostado chips, corn on the cob, hard breads, raw vegetables, steak, etc. NO CHEWING GUM OR ICE! By cutting your food into smaller pieces, you can avoid a great deal of chewing thereby eliminating additional stress to your jaw joints.
- As much as possible, consciously disengage your teeth - keep them slightly apart except when chewing or swallowing. The rule to remember is "lips together, teeth apart".
- Your sleep position is vitally important. If possible it is best to sleep on your back, perhaps with a pillow under your knees if that is more comfortable. You may want to also use pillows to support your sides. This would discourage turning over while asleep. Do not use firm, full pillows under your head. There are various orthopedic pillows available that are helpful in reducing head and neck pain. A rolled bath towel placed under your neck instead of a pillow may be preferred. If you sleep away from home, take your neck pillow (or a towel) with you. DO NOT SLEEP ON YOUR STOMACH. If you must sleep on your side, put a pillow between your knees, a pillow between your arms and keep your head pillow from pressing against your TM joint. Do not sit or sleep under ceiling fans or vents as this will aggravate sensitive muscles and joints.
- Do not sit with your chin resting on your hand. Protect your yawns by placing your fist under your lower jaw to prevent an extra wide opening. When talking on the telephone, do not support the receiver with your shoulder.
- Practice good posture. Keep your head up, chin out, shoulders squared and back straight.
- Support your lower back when sitting. If you must sit for long periods of time (at a desk, in a vehicle, etc.) try to stand and move around frequently in order to adjust and stretch your muscles.
Remember - these hints are not intended as a substitute for seeking professional help. While you will experience some minor relief when employing these techniques, they are not a permanent solution to the problem. Please contact a trained clinician of the American Academy of Craniofacial Pain as soon as possible.
CAUSES OF TMJ DISORDERS
According to statistics published in the Journal of the American Dental Association in 1990, 44% to 99% of TMJ problems are caused by trauma. By trauma, we mean an injury as obvious as a blow to the jaw with a fist or something as subtle as a whiplash injury, with or without direct trauma to the head or jaw. (*JADA 1990;120:267)
Cervical Acceleration/Deceleration (Whiplash)
When one is riding in a vehicle and is struck by another vehicle, often soft tissue injuries in the neck, back, and TMJs may occur. Although the injury may occur from any direction, usually it comes from the rear. When a cervical acceleration/deceleration (CAD) or whiplash injury is produced, the head is thrust in the direction of the impact. For example, when sitting at a traffic light and a car is struck from the rear by another car, the heads of the occupants in the first vehicle are thrust backwards towards the rear. As the head is thrown backwards, inertia (remember Newton's Law that a body at rest tends to stay at rest until acted upon by an outside force?) causes the lower jaw or mandible to remain where it was in space for about 250 milliseconds (about 1/4 of a second). This violent motion, causing the head to be thrown backwards, also causes anterior mandibular displacement as the mouth is forced open. Then, the mouth is slammed shut and backwards. This fast movement can produce stretching and/or tearing of the ligaments and connective tissues in one or both TMJs, bleeding, and often, displacement of the articular disc in the TMJ.
At the moment of impact from the rear, as the head is thrust backwards, the vehicle is actually accelerated forward as the body of the occupant moves backward, thus forcing him or her into the seat. As the mouth is thrown open, producing TMJ injury, the head either hits the head rest or extends over the headrest. Then, as the vehicle comes to rest, the occupant is still moving forward until he or she is stopped either by a lap belt and shoulder harness, or, the steering wheel or windshield. During this last movement, the head is thrust forward while inertia causes the mandible to be thrust suddenly backward, traumatically closing the mouth violently. This motion may fracture or chip teeth and further injure the posterior part of the TMJ. Note: with the development of all the above injuries, no direct trauma to the head or jaw has yet occurred, demonstrating that direct trauma IS NOT NECESSARY for a whiplash injury to severely damage the TMJs and teeth.
Air Bag Deployment
Direct trauma to the mandible in auto accidents, like indirect trauma in whiplash injuries, are both known to produce TMJ injuries. Recently, however, the advent of air bags, which no doubt have saved numerous lives, has been implicated in causing TMJ problems. Personally, I've seen several patients who have been hit only with air bags which deployed when the car was impacted in an accident.
Opening Too Wide
All joints have limitations to movement and the TMJ is no exception. If you're open wide for a long time, or if your mouth is forced wide open, ligaments again may be torn. Swelling and bruising develop and disc dislocation may occur. For example, if your mouth is open for a long time at the dental office while having a tooth prepared for a crown, the joint can dislocate. This rarely happens without a prior history of trauma; however, it does happen. Also, this type of injury may occur if someone's mouth is opened too wide when they are being put to sleep for surgery. Again, both of these examples are accidental and consequences of the given procedures.
Bruxism is the abnormal grinding of the teeth. If grinding continues, TMJ injury may develop due to biochemical changes in the connective tissues of the joint. Bruxism usually occurs during sleep. That is why so many people do not realize that they are bruxers. One indication that a person is a bruxer is sore jaw muscles when waking in the morning. Some researchers feel that the constant grinding of the teeth causing pressure on the TMJs may injure the ligaments, thus allowing for the disc to dislocate. At the very least, bruxism produces muscle pain, sensitive and worn teeth.
Some dentists feel that orthodontic treatment, or braces, might be a cause of TMJ problems. By moving teeth with orthodontic appliances, malocclusion is produced during treatment. Also, people undergoing orthodontics do report sensitive teeth, pain in the jaw muscles and even bruxism. However, as with malocclusion, there has been no scientific controlled study to prove that orthodontic treatment produces a TMJ problem.
Malocclusion is simply a bad bite. Malocclusion may be produced by poor development of the jaws or removal of teeth without replacement, a high dental restoration, a poor fitting denture or partial denture, or a displaced TMJ disc
People who appear to be double-jointed actually suffer from a problem termed ligament laxity. If this condition occurs, then the joint appears to be double-jointed or, loose. This definitely can happen to the TMJs. Ligament laxity is a fairly common problem in active young women who suffer with TMJ problems (and injuries to other joints). These are the young ladies who are often cheer leaders or gymnasts. They seem to be able to contort their bodies into positions which are not normal.
Stress has many effects on our bodies: some good and some bad. Stress may be physical, psychological or both. Physiological changes can produce muscle tightness and pain and if you are subjected to chronic stress, these physical changes may produce harmful effects. For example, people subjected to chronic stress develop ulcers, diarrhea, tension headaches, muscle tightness and other physical symptoms. Stress is just like throwing gasoline on an existing fire: the fire is a TMJ problem and the gasoline is stress. The gasoline causes the fire to flair up and burn widely for a time, but the gas did not produce the fire (or, TMJ problem), it just made the problem worse. This is how it appears that stress acts in conjunction with a TMJ problem. Muscles tighten, teeth clench, abnormal pressure is forced against the TMJ disc, and if the ligaments are weak or if the patient is one that has ligament laxity, then the disc may dislocate.
Various diseases can cause or aggravate TMJ problems. Immune disorders such as rheumatoid arthritis, psoriatic arthritis, and systemic lupus erythematosus can produce inflammation in the TMJ. In addition, viral infections such as mononucleosis, mumps and measles can cause damage to the surfaces of the TMJ, which ultimately can lead to an internal derangement or damage to the articular disc.
SYMPTOMS OF TMJ
Because many different symptoms of TMJ exist, discovering a proper diagnosis is difficult. However, there are a few classic symptoms which involve the TM joints, ears, head, face and teeth.
The most common symptom of TMJ is jaw joint clicking (popping, snapping). This clicking sound may be so loud that it can be heard by others while you chew. There may or may not be pain in the joint itself with the sound of a click or pop. But one thing is for sure: if there is a displaced disc, as is usually the case when a click occurs, then the muscles that move the jaw while chewing are more tense than normal. This tenseness can and does cause muscle, facial, head and neck pain.
Locking of the TMJ may be noticed simply by catching of the lower jaw as it opens. Sometimes, the person with a locked joint must move the jaw to one side or another in order to open wide. Or, a person might have to open until he hears and feels a loud pop, at which point the jaw actually unlocks
Change in biteA dislocated TMJ may also be noticed by a change in the dental occlusion, or bite. If the TMJ disc goes out of place, the bones and disc do not fit together properly and therefore, the bite of the teeth changes.
Headache is one of the most common symptoms of a TMJ problem. Usually the TMJ headache is located in the temples, back of the head, and even the shoulders. Clenching and grinding of the teeth, both of which may be TMJ symptoms, produce muscle pain which can cause headache pain. Also, a displaced disc in the TMJ may cause pain in the joint which is often referred into the temples, forehead or neck. These headaches are frequently so severe that they are confused and treated (with little success) for migraine headaches or abnormalities in the brain.
Due to the close anatomical relationship of the TMJs to the ears, an injury to the TMJ often causes various ear symptoms. Some of the symptoms may be ear pain, fullness or stuffiness, and even a loss of hearing. That's why so many TMJ sufferers first see their family doctor and an ear specialist before even considering seeing a dentist for a possible TMJ problem.
The teeth may become sensitive because of jaw activities such as clenching of the teeth or grinding of the teeth when the disc of the TMJ is displaced. Patients often see their dentist with the complaint of pain in the teeth and usually the doctor can find no cause. Frequently (and very unfortunately), unnecessary root canals and even tooth extractions are performed in an attempt to help a suffering person. What's worse, after these invasive and non-reversible procedures, patients still have their pain, only now it has increased!
Many other symptoms may be associated with TMJ. Often, pain will be felt in the shoulders and back due to muscle contraction, a condition called myofascial pain dysfunction syndrome. Dizziness, disorientation and even confusion are also seen in some people who suffer with TMJ.
Depression is common with TMJ. This may be due to the fact that no one really believes there is a problem causing such pain and suffering. Also, plenty of scientific evidence shows that chronic pain patients (which nearly all TMJ patient can claim) have changes in chemicals in the brain (termed neurotransmitters) as result of the pain. These chemicals can and do produce depression. Along with depression comes an inability to get a good night's sleep. This may be due to TMJ pain itself or, changes in the brain's neurotransmitter chemicals which produce stimulation even though the TMJ sufferer is asleep. Sufferers usually wake feeling like they never slept or at least, did not sleep well. This lack of sleep not only makes their pain seem worse, but also adds fuel to the fire of depression.).
TMJ patient may also suffer with photophobia, or light sensitivity. A dislocated TMJ may produce pain in and behind the eye which can cause sensitivity to light. Blurred vision and eye muscle twitching are also common in TMJ patients.
A final common symptom is ringing (termed tinnitus) in the ears. This sound may be caused by many different problems such as, working around loud noises or taking too much aspirin or ibuprofen, or a displaced disc in the TMJ. This is a very frustrating symptom and oftentimes does not stop after successful TMJ treatment. We often refer these patients for ENT evaluation or to an audiologist for treatment in conjunction with our TMJ treatment.