Daily Archives: June 18, 2012
Every day I wake up with a major headache (what a coincidence…you, too?) but recently they seem to be getting worse; and my cheeks hurt – oh, and of course, my neck. I’m not talking the general stiffness type of pain – I’m talking the severe pain when your head spins as you get out of bed and being unable to face any light without my face exploding, and I can forget about turning my head in any direction.
Supposedly, this could all be Temporomandibular Joint Disorder (TMJD). It is rather common for patients to complain of suffering chronic fatigue along with all the pain of FM, but it seems to me that too often perhaps doctor and patient neglect to discuss the pain of TMJD, which is also seen commonly in FM patients. Perhaps this is because the patient and doctor think it is a dental problem, better left to a dentist. Unfortunately, many dentists think TMJD is at least in part a muscular problem, better left to the patient’s medical doctor.
The reality is that the many patients suffering from fibromyalgia unfairly end up facing the facial pain of TMJD alone.
What is the TEMPOROMANDIBULAR JOINT?
The TMJ is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. Within the TMJ, there are moving parts that allow the upper jaw to close on the lower jaw. This joint is a typical sliding “ball and socket” that has a disc sandwiched between it. The TMJ is used throughout the day to move the jaw, especially in biting and chewing, talking, and yawning. It is one of the most frequently used joints of the body.
The TMJs are complex and are composed of muscles, tendons, and bones. Each component contributes to the smooth operation of the TMJ. When the muscles are relaxed and balanced and both jaw joints open and close comfortably, we are able to talk, chew, or yawn without pain.
You can locate the TMJ by putting a finger on the triangular structure in front of the ear. The finger is moved just slightly forward and pressed firmly while opening the jaw. The motion felt is from the TMJ. You can also feel the joint motion if you put a little finger against the inside front part of the ear canal. These maneuvers can cause considerable discomfort to a person who is experiencing TMJ difficulty, and doctors use them for making the diagnosis.
TMJD can cause a patient to experience nausea, headache, dizziness, and difficulty chewing due to jaw pain. By some estimates, 90% of FM patients experience facial and jaw pain; many of these same patients are thought to suffer from TMJD. You can see how it might be difficult to make a diagnosis.
TMJD affects the functioning of the jaw, but it can also result in muscle pain throughout the head and neck. A person suffering from TMJD can suffer a range of problems, from headaches to a “locked” jaw. When coupled with the problems seen in FM, TMJD can be almost disabling. This is all the more concerning, when data shows that over 75% of people with FM also suffer from TMJD.
There is a school of thought that divides TMJD into two types:
- Joint TMJD, caused by damage to the cartilage or ligaments of the temporomandibular joint. This can in turn be the result of prior injury, dental problems, or grinding of the teeth (also known as ‘bruxism’). This can present as popping or clicking of the jaw joint, the inability to open the mouth very wide, TMJ pain, and headaches.
- Muscular TMJD, which more commonly affects the FM patient. This affects the muscles used to chew and move the face, neck and shoulders. Muscular TMJD can be caused by a lack of sleep, muscular trauma, and stress. It can present as headaches, and difficulty with opening and closing the mouth.
Stress has a major impact on both FM and TMJD. Stress can cause some to clench or grind their teeth, causing continued stress on the muscles and the TMJ, making both joint and muscular TMJD worse. Stress must be brought under control: life styles may need to be changed, and medications may be necessary to relax the facial muscles, lessen the pain, and relieve the sleeplessness. Massage can certainly be of great value in such cases. Dental intervention is needed for those with missing teeth; and an orthotic occlusal plate may help to stabilize the bite and bring balance to the muscles of the jaw and head and neck areas. I had an NTI-tss (nociceptive trigeminal inhibitor) dental guard fitted by my dentist. Nociceptor nerves sense and respond to pressure. The trigeminal nerve supplies the face and mouth. The NTI appliance snaps onto the front teeth. Normally when the mouth is closed, the upper and lower front teeth overlap: The NTI prevents this overlap and translates the bite force from attempts to close the jaw normally into a forward twisting of the lower front teeth. The intent is for the brain to interpret the nerve sensations as undesirable, automatically and subconsciously reducing clenching force. Unfortunately, for patients who do not stop subconsciously clenching, the NTI can lead to more severe damage from clenching. I find that I just clench harder, but now it’s onto a piece of plastic
The efficacy of such devices has been debated. Randomly controlled trials with these type devices generally show no benefit over other therapies.
Unfortunately, as with so many things in medicine, the economics of properly caring for the TMJD patient becomes a barrier for so many patients. This is not surprising, in light of the two types of TMJD discussed above.
Insurance companies often do not cover the cost of treating TMJD claims for the following reasons:
- They see the two types of TMJD as representing a controversy about both the causes and treatments of TMJD.
- There is not a large amount of scientific validation of TMJD therapies.
- The perceived conflict regarding whether TMJD is a medical or a dental problem results in a tug-of-war between medical and dental insurance companies, resulting in a situation where neither insurance group feels it is their responsibility to pay.
Now, the whole reason this post came about was because I had heard about using botox to stop the teeth grinding. Botulinum (Botox) can lessen bruxism’s effects. An extremely dilute form of Botox is injected to partially weaken muscles and has been used extensively in cosmetic procedures to relax the muscles of the face.
Botox treatment typically involves a number of small injections into the masseter muscles. It takes a few minutes per side, and you can start to expect feeling the effects as quickly as the next day, although 3-4 days is more common. The optimal dose of Botox must be determined for each person as some people have stronger muscles that need more Botox. This is why you should always see someone specifically trained in the application of Botox for treatment of clenching.
The effects last for about three months. Over time it is usually possible either to decrease the dose or increase the interval between treatments.
So, later today, I am phoning a dentist I found that specialises in this kind of treatment to see how much it costs and if my medical/dental insurance covers it – Please, oh please!