TMJ: temporomandibular dysfunction and associated pain

This article has been on my mind for quite some time and, in the times we live in now, far from leaving a lot of free time, mentally it has us all very stressed.

Bruxism, ear pain, chewing pain, masticatory myofascial syndrome, temporomandibular dysfunction, etc. All these words, without meaning exactly the same thing, refer to a set of conditions, pain that is located in front of the ear, which generally worsens when chewing, and that without being a very intense pain is quite disabling. From now on, we will call it TMJ.

In order to explain and understand it, we will talk about:

  • The symptoms with which it presents itself.
  • Anatomical explanation of why it happens.
  • What tests we use to diagnose it.
  • Treatment it has.

I start by saying that it is something much more frequent than it seems. It is estimated that up to 30-40% of the population at some point may have TMJ pain. So if this happens to you, you know that you are not alone.

Sometimes the pain is also accompanied by a ringing in the ears, the famous tinnitus, and sometimes, because of this, multiple consultations are made to the otolaryngologist who does not find infections or alterations of the ear.

Other times, the pain is accompanied by noises in the joint when chewing or even that the jaw is stuck and patients tell you that they have to unhinge the jaw to chew.

We could say that it is typically a localized pain in front of the ears, which goes up to the temples, down to the neck and radiates to the maxillae or jaw. In many cases it worsens when chewing. Other times, the pain is more identified as a headache.

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This pain typically occurs in flare-ups, which last from a few days to a couple of weeks. But then it goes dormant.

Usually, these outbreaks worsen considerably with stress. Like the situation we are experiencing for example.

As you can see, it seems to behave very unevenly, but believe me we usually diagnose it at a glance.

But why does it occur?

Here we enter the anatomical part. In front of the ears is the joint that moves the head with the skull. I always explain that it is like a knee but smaller, since it is formed by two bones (the skull bone and the jaw bone, in the middle it has a meniscus). It also has a peculiarity. It is the only joint in the whole body whose movement depends on the other side.

We cannot move only the joint on one side, we necessarily need to move both of them. Also, another important condition of this joint is that we do not stop using it, due to the fact that we are used to eating, talking… every day and now, almost every hour.

Well, this joint is located just in front of the ear, in fact, it is separated only by the auditory canal. In addition, the muscles of mastication, which in turn are responsible for stabilizing the skull, the jaw and the cervicals, are inserted.

Some of these muscles are inserted into the mini-disc between the two bones. Having said this, can you imagine what will happen when we have some kind of contracture at this level? voila. Pain. And a pain that is also a pain, because when you have a contracture in the shoulder you stop moving it, but if you have a contracture at this level it is not so easy to do it?

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So, this could explain the muscular part of the problem. The question is that the alterations of the TMJ, not only give that muscular problem or that is due only to a muscular origin. For example, when the chewing movements are not adequate because we are missing teeth or when our way of biting is not adequate and the teeth do not fit together… If our chewing movements, what is known as the dynamics of chewing, are not adequate, they can cause problems at the articular level that can secondarily cause pain and muscular problems. Other times parafunctions are added to that, the famous bruxism.

Did you know that the masseter has more strength than the quadriceps?

Bruxism or teeth clenching can be conscious (in moments of stress) or unconscious when sleeping. In turn, it can be as force only or it can be presented as teeth grinding. In any case, if you add to this the predisposition to present problems at the articular level, stress, lack of teeth, malocclusion or the normal articular degeneration that occurs as we get older, you have the ideal cocktail.

How do we diagnose it?

The clinical examination will give us a good idea. On many occasions, most of them even, we usually request an OPG to rule out organic causes at the joint level.

After the examination, we usually get an idea of whether the articular component of the problem is more or less predominant than the muscular alteration. On other occasions, after the evolution, we request joint MRI scans to quantify the joint damage.

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And most importantly, how do we treat it?

Well, if the origin of the problem is multifactorial, it seems logical that the treatment should also be multifactorial. We more or less divide the treatment into surgical (reserved for articular problems almost exclusively) and conservative treatment (for muscular-articular problems) and at least initially for both.

Conservative treatment is based on a series of pillars, which in themselves, will have the function of spacing out the outbreaks of pain and shortening their duration:

  • Pharmacological treatment of pain and muscle pain with analgesics and muscle relaxants, administered in short batches for the duration of the outbreaks.
  • Rehabilitation / physiotherapy treatment of TMJ, masticatory and cervical musculature.
  • Hygienic dietary measures: at the time of the outbreak, soft diet. The joint should be left as much alone as possible. And that means avoiding excessively hard foods. For example, eating an apple in bites or whole nuts. Of course, nail biting, chewing gum, pipe chewing… is also strongly discouraged.
  • Michigan type unloading splint: this type of splint is made by dentists, and its correct use and maintenance is almost as important as having it. Periodic check-ups should be carried out to ensure that the splint fits and performs its function.
  • Treatment with botulinum toxin injected in the masticatory musculature, flowerpots and temporaries helps a lot to control and relax. The downside is that every 4-6 months it has to be injected again.