Temporomandibular Joint Musculoskeletal Dysfunction

Dentistry must expand its vision to include a comprehensive view of the relationship of the mandible to the skull and the relative relationship of the cranial bones to each other. When occlusal contacts are altered through disease, neglect, or with sincerely well intended efforts at restoration, the results may produce a deviation of terminal mandibular posture, With the mandible out of its normal position in relation to the skull, as tooth contacts occur, this deviation forces the structures to function under distress, often causing a craniomandibular disorder with localized pain to the head, face, neck, mouth, tongue, ears and/or eyes, with later observable involvement through the systems of the body.

Many clinical dentists are extremely alert to factors causing pain directly in teeth and supporting structures. However, these same clinicians may consider pain elsewhere in the head and neck as being completely outside their sphere of influence. It then follows that dental practitioners are routinely placing restorations in patients who for years have been suffering with severe and chronic headache, neck and ear pain, and systemic symptoms which could be a direct result of the relationship of the mandible to the skull.

The dentist is frequently unaware that the patient has these existing symptoms, because it would never occur to him or her to question the patient concerning such symptoms. The dentist may hold the opinion that a patient suffering from chronic headache should be consulting a physician. This might be necessary, but the dentist should initiate a comprehensive differential diagnosis to determine if a craniomandibular disorder is present.

It is unlikely that the patient will ever volunteer information concerning the disorder to the dentist who is making an examination for caries. If the patient has visited his or her physician he or she may have heard that the symptoms are attributed to “nerves”, “tension”, “menopause” or similar factors.

This is where dentistry must assume its responsibility in this “no man’s land”. Dentistry must accept the fact that the mandibular posture determined is critical. The mandible must be constantly and precisely returned to that position which is demanded by the intricate musculature involved in the head and neck area, thus making the dentist and oral orthopedist. All dental restorations must be thoroughly planned and integrated to meet this muscle demand.

Dental science has had to await the development of instrumentation to move forward in diagnosis and treatment of such patients, but this time has come. We now have these capabilities with the use of transcutaneous electrical neural stimulators, portable electromyography apparatus, mandibular kinesiographs, and Doppler effects with ultrasound, to name a few. Clinical judgment can now be based on facts instead of opinion.


Richard Coy, Journal of Craniomandibular Practice

The lack of undergraduate teaching of chronic pain management, diagnosis and treatment of temporomandibular joint/musculoskeletal dysfunction and related disciplines in dental schools is well documented. A recent survey in the Journal of Dental Education indicated that two fifths of American dental school students currently are not exposed to a course in dealing specifically with the diagnosis and management of chronic pain. The article further suggests that “…The interrelationship of teeth to muscles and joints should be vividly demonstrated and the damaging results form disharmony on one or more of these elements be made clear. An appreciation of harmonious interrelationship of all the elements, the discord that can result from dental intervention, must be one goal of any educational effort.”

The role of the dentist in diagnosis and treatment of orofacial pain has been well described by many authors. Bell defined the incumbent responsibility of the dentist when he wrote, “ Upon the dentist rests a great burden of responsibility for the proper management of pain in and about the mouth, face and neck.” Neuromuscular Dental Diagnosis and Treatment, Robert R. Jankelsen, Ishiyaku EuroAmerica, Inc. Publishers, 1990.

Patients very often will self-diagnose, especially strong, chronic “bad” headaches as “migraine,” usually without the diagnosis of a neurologist. The typical headache TMJ patients exhibit is temporal headaches. The reason TMJ patients most often suffer from temporal headaches is because the temporalis muscle, which is located at the sides of the head, is the positioning muscle of the mandible, or lower jaw. If the teeth clenched together place the mandible at an unfavorable relationship to the head and neck complex, the temporalis muscle is overactivated and goes into spasm. Overworked muscles of chewing, like overworked muscles in any sport, can fatigue, be filled with toxins and cause pain perceived as headaches. Clenchers and grinders often wake up in the mornings with temporal headaches. This misalignment of the mandible is an orthopedic problem which can be corrected, thus eliminating temporal headaches related to the bite or occlusion.

Ear symptoms are very common with TMJ dysfunction. ENT specialists understand that due to the very close proximity of the TMJ to the ears, if there is no organic problem in the ears, then there is probably a connection of dizziness, tinnitus, ear congestion, ear pain and even inner ear related nausea to TMJ issues. An easy test for this is to place a finger in each ear and press lightly toward the face. If you can feel the condyle (the bony part of the TMJ) of the mandible when you tap your teeth together, then you are likely to have ear symptoms.

Ear symptoms are very common with TMJ dysfunction. ENT specialists understand that due to the very close proximity of the TMJ to the ears, if there is no organic problem in the ears, then there is probably a connection of dizziness, tinnitus, ear congestion, ear pain and even inner ear related nausea to TMJ issues. An easy test for this is to place a finger in each ear and press lightly toward the face. If you can feel the condyle (the bony part of the TMJ) of the mandible when you tap your teeth together, then you are likely to have ear symptoms.

TMJ patients often report trigger points of pain in the neck and shoulders. Palpating these muscles usually feels good to the patient because it is like giving them a massage, or simply stimulating and working out the knots in their neck and upper back caused by the tightening and hyperactivity of these muscles. The combined hyperactivity of these muscles sometimes constricts, or puts pressure on the radial nerves which exit the nervous system at the level of the neck and innervate the upper limbs. This constriction, or tightening, on the nerves of the arm may be manifested in tingling of the fingers.

There is a muscle that attaches to the back of the eye socket on one end and to the mandible on the other end. This muscle is called the sphenomandibularis. If there is hyperactivity in the chewing muscles, this muscle can also be involved and refer pain to the back of the eye.

Other symptoms that can be associated with TMJ are pain in the muscles of the face, fatigue of the whole body, getting tired chewing gum, getting tired smiling too much, frequent coughing, blurred vision, swelling of the face, cracks in the corners of the mouth. As one can imagine, any combination of these symptoms mentioned can greatly affect the quality of one’s life.

Other symptoms that can be associated with TMJ are pain in the muscles of the face, fatigue of the whole body, getting tired chewing gum, getting tired smiling too much, frequent coughing, blurred vision, swelling of the face, cracks in the corners of the mouth. As one can imagine, any combination of these symptoms mentioned can greatly affect the quality of one’s life.

The area of the brain that controls the chewing muscles and the TMJ also controls wakefulness and alertness. So, if there is hyperactivity in that region of the brain involving the mouth, sometimes there is overstimulation in the neighboring regions of the brain. This crossing over, excess stimulation can actually cause a patient to have insomnia.

Other symptoms that can be associated with TMJ are pain in the muscles of the face, fatigue of the whole body, getting tired chewing gum, getting tired smiling too much, frequent coughing, blurred vision, swelling of the face, cracks in the corners of the mouth. As one can imagine, any combination of these symptoms mentioned can greatly affect the quality of one’s life.

Other symptoms that can be associated with TMJ are pain in the muscles of the face, fatigue of the whole body, getting tired chewing gum, getting tired smiling too much, frequent coughing, blurred vision, swelling of the face, cracks in the corners of the mouth. As one can imagine, any combination of these symptoms mentioned can greatly affect the quality of one’s life.

Other symptoms that can be associated with TMJ are pain in the muscles of the face, fatigue of the whole body, getting tired chewing gum, getting tired smiling too much, frequent coughing, blurred vision, swelling of the face, cracks in the corners of the mouth. As one can imagine, any combination of these symptoms mentioned can greatly affect the quality of one’s life.