What actually is jaw pain?
Did you know that some physiotherapists can help you deal with jaw pain? The temporomandibular joint (TMJ) is located between the cheek and the ear.
Pain at the TMJ can be mild to severe, isolated to the joint or widespread to the neck and head. It can become so debilitating that you could struggle with chewing, eating or opening your mouth normally.
10-15% of the population is affected by TMD (temporomandibular disorder) and it is more common in women between the ages of 20 and 44. There’s also a high correlation between headache and neck pain.
Why does it occur?
Habitual grinding and clenching of the teeth are strong factors, as well as high levels of stress and anxiety. Sudden injury or trauma can also cause TMJ pain as can braces or structural abnormalities but are less common.
I’ve found that stress and anxiety is the most common factor which often triggers or greatly contributes to myofascial TMD symptoms.
Picture this: You may be overworked or dealing with relationship problems and then you find out your holiday has to be cancelled for reasons beyond your control. Muscle tension builds up in your upper back (thoracic joints), gripping onto your shoulder blades (rhomboids) as you breathe shallower and more rapidly. The tightness climbs on top of your shoulders (upper trapezius) so you shrug them up in an attempt to shake it off but it makes it worse. The sides of your neck ache and pull (scalenes, sternocleidomastoid) as you desperately attempt to stretch it out.
There is no reprieve, so you grind your teeth (masseters) and get on with it because you have a deadline to meet. All the while, your neck joints feel increasingly stiff as you crain over your keyboard so hold your head in your hand as you take another phone call which makes you clench your other fist. You’ve definitely got a headache now. It’s throbbing at the base of your skull (suboccipitals) and seems to pound behind one eye.
You’ve been waking in the morning for weeks or months now with a stiff jaw, a neck spasm and bonus fingernail marks in your palms from your nighttime clenching. Yawning is a dance of danger - you worry it might hurt or click if you let it relax too much. You cut up the apple instead of eating it whole because you’re used to being able to take a bigger bite than this. Eventually you can’t even eat spaghetti or bite your nails (another sign of stress) because somehow you can’t jut your jaw forward enough anymore.
You finally go to see the dentist who checks your enamel and they either say
A) You haven’t worn down enamel so no need for a night splint or
B) There are signs of grinding so they make you a splint which gives you extra bad morning breath but seems to help with the symptoms a bit.
You wonder if you’ll ever be able to have a pork roll pain-free again.
Of course, not everyone experiences jaw pain this dramatically but others may read this and relate to 99% of this picture. Even if you think this is only 20% you, it’s worth looking into - why wait for it to get even worse when you could prevent this from happening?
Symptoms of TMD (Temporo-mandibular disorders)
If you experience any of the following symptoms it is likely you are experiencing problems at your TMJ:
Waking with a stiff neck, jaw or headache
Painful popping, clicking or clunking with movement
Painful asymmetrical movement
Difficulties with yawning, laughing, singing and eating
Grinding or clenching during the day or night
70-86% of TMD patients have recurrent headache while 14-21% of those who have headache have TMD signs/symptoms.
What does the jaw actually look like?
The joint itself is like a “ball-and-socket” with a disc of cartilage in between. There are ligaments attaching the bones together and to the ear. There is a close relationship between the jaw and hearing or tinnitus.
The small disc which slides with movement is held in place by “bucket-handle” ligaments. At times it can get displaced but normally it sits like a baseball cap on the “ball” part of the joint.
There are several muscles involved at the jaw that coordinate various movements. Movement of the disc must coordinate with jaw action, stabilisation, elevation, retraction and is also influenced by the teeth. Even light contact of the teeth requires muscle activity to bring them together.
What’s in the assessment and treatment?
Over 50% of TMD are of muscular (myofascial) origins while the rest are due to inflammation at the joint. To work out the difference in a physiotherapy assessment, we not only look at the jaw and ear (sometimes with a gloved hand, like a visit to the dentist) but also the neck and head movements and posture.
Relief from pain comes from relaxing the TMJ muscles which are overworked and strengthening the muscles which are underperforming.
Treatment includes resolving muscle spasm at the neck and jaw with massage or dry-needling. We also mobilise stiff joints, prescribe shoulder, neck and jaw exercises. If appropriate, a referral to a dentist or GP will be provided.
Behaviour modification like decreasing clenching or grinding must also be addressed. I find that a huge part of managing TMD effectively is gently identifying the factors which trigger or contribute to the behavioural conditions. This is so we can gradually make realistic life-style changes and devise sustainable ways to manage the factors. If necessary we can co-manage with a counsellor to create an effective pathway to recovery long-term.
So should I book in soon?
Yes! I’ve treated many workers, especially in the corporate sector with TMD in the last few years and the results are much better when addressed earlier in the piece. Research findings show that conservatively managed TMDs will resolve within 3 months but in my experience, significant improvement can be made in 2-6 weeks.
So book in a session as soon as possible so that you can get back to eating, sleeping and yawning like a normal person again!
References
Bush FM and Harkins SW (1995): Pain-related limitation in activities of daily living in patients with chronic orofacial pain: psychometric properties of a disability index. Journal of Orofacial Pain 9:57-63.
Ciancaglini R and Randaelli G (2001): Relationship between head and TMD: epidemiologic study. Dental Abstracts 46:239.
Clarke GT et al (1993): Co-advication of sternocleidomastoid muscles during maximum clenching. J Dent Res 72:1499-1502.
Dworkin SF et al (1990): Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. Journal of the American Dental Association 120:273-281.
Furto ES, Cleland JA et al (2014): Manual physical therapy interventions and exercises for patients with temporomandibular disorders. J Cranio Prac 24:283-291.
Goncalves DAG et al (2011): Temporomandibular disorders are differentially associated with headache diagnoses - A controlled study. Clin J Pain 27:611-615.
Gremillion HA and Mahon PE (2000): The prevalence and etiology of temporomandibular disorders and orofacial pain.Texas Dental Journal 117:30-39.
LaTouche R et al (2009): The effects of manual therapy and exercises directed at the cervical spine on pain sensitivity in patients with myofascial temporomandibular disorders. Journal of Oral Rehabilitation 36:644-652.
Manfredini D et al (2011): Research diagnostic criteria for temporomandibular disorders: a systematic review of axis 1 epidemiologic finding. Oral Surg Oral Med Oral Pathol Oral Endod 122:453-462.
McNeely ML, Olivia SA and Magee DJ (2006): a systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders. Physical Therapy 86:710-725.
Melis M, Di Giosia M, Zawawi KH (2012): Low level laser therapy for the treatment of temporomandibular disorders: A systematic review of the literature. Cranio 30:304-312.
Melzack R (1999): From the gate of the neuromatrix. Pain (suppl) 6:S121-S126.
Okeson JP (2005): Bell’s Orofacial pain. The clinical management of orofacial pain. (6th ed), Chicago: Quintessence Publishing Co, Inc.
Ohrbach R et al (2013): Clinical orofacial characteristics associated with risk of first onset TMD: the OPPERA prospective cohort study. J Pain 14(12 Suppl): T33-T50.
Reik L, Jr and Hale M (1981): The temporomandibular joint pain-dysfunction syndrome: a frequent cause of headache. Headache 21:151-156.
Schiffman E et al (2014): Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications. J Oral and Facial Pain and Headache 28(1):6-27.
Schokker RP, Hansson TL, Ansink BJ (1990): Craniomandibular disorders in patients with different types of headache. Journal of Craniomandibular Disorders 4:47-51.
Sessle BJ (2000): Acute and chronic craniofacial pain: brainstem mechanisms of nociceptive transmission and neuroplasticity, and their clinical correlates. Crit Rev Oral Biol Med 11:57-91.
Svensson et al (2004): Association between pain and neuromuscular activity in the human jaw and neck muscles. Pain 109:225-332.
vonPiekartz H and Ludtke K (2011): Effect of treatment of temporomandibular disorders (TMD) in patients with cervicogenic headache: a single-blind, randomized controlled study. Cranio 29(1), 43-56.
Opmerkingen