By Richard E. Klein, Dds
Why is TMD called the great imposter?
Psychiatrists might evaluate a depressed person by evaluating for a hypoglycemia diet or obstructive sleep apnea, etc. Also, when hip problems surface, the physician will evaluate a short leg discrepancy, as well as their patient’s lifestyle, along with many other considerations as to why they are there with their complaints.
Physicians evaluate knee problems by watching a person’s gait or looking for foot pronation, and a multitude of many other observations. They look at anatomy that is distant to where the patient is complaining. The TM joint is a joint. Any physiatrist might treat joints with injections, pressure relief, recommend alterations in activities of daily living and lifestyle, and utilize pharmaceuticals, physical therapy and/or physical medicine techniques.
The TM joints, acute or chronic, should be treated as any joint in the body would be by a physiatrist or pain management specialist. Orthotics are sometimes and generally necessary, but not always. When there is a diagnosis of temporomandibular disorder, its causality is not always malocclusion or a recent injury. The symptoms may simply be the result of muscle guarding tenseness in areas related to the craniomandibular complex that are not eliciting pain in the usual areas. For example, most temporomandibular joint dysfunctions include popping or clicking, jaw pain or headaches; however, these symptoms do not have to be present when TMD is a problem, just as physiatrists understand for other joints in the body.
I learned this back in the 1970s. An 8-year-old girl came to my office as a new patient. Her health history form documented that she had slowly lost her hearing in her left ear. No other symptoms indicated that she had a TMJ problem since she could chew; she didn’t hurt, she didn’t have pain in her face or her jaw, and she didn’t click. Her otolaryngologist was perplexed. Her previous dentist had extracted a deciduous molar. This resulted in the opposing dentition to naturally extrude, so this girl basically was biting with malocclusion.
I did as any dentist would; I placed a space maintainer with an occlusal metal attachment to hold the upper tooth from extruding again and I equilibrated the maxillary tooth. A month later, she and her parents came back with a cake and thanked me for bringing her hearing back. I thanked them for the cake and told them I had no idea what happened, but would look it up. Medical ENT textbooks basically said the ear and the TM joint both are initially formed in the fetus from Meckel’s cartilage. It then, less informatively, stated that the ear and the TM Joint have confusing symptoms since they are so closely anatomically related. Well that didn’t help much, but I was still happy for my patient, even though I did not know why.
Today, some insurance adjusters are not aware of the advances in TMD research and routinely deny payments for TMD unless the “jaw is stuck or hurts.” Well, we now know that the tympanic membrane is protected by the tensor tympani muscle. Its purpose is to protect the eardrum when loud noises are present that could damage the eardrum. The 8-year-old girl had a temporomandibular joint problem without tenderness or pain. Her symptom of loss of hearing was the only overt sign. Over the years, I’ve seen many patients that have had blurred vision without jaw pain and lacrimation without TMJ clicking, retroorbital pain without jaw tenderness, ear congestion without any other TMD sign or symptom, who subsequent to treatment for TMJ, experienced amelioration of the eye or ear problems. TMD does not necessarily always have to be accompanied by jaw pain, headaches or clicking.
“The TM joints, acute or chronic, should be treated as any joint in the body would be by a physiatrist or pain management specialist.”
Dysphagia can occur if the anterior digastric muscles tense and torque the hyoid bone. A small amount of Marcaine injected to the ligamentous attachment of the muscle on either side of the symphysis of the chin can help them chew and swallow. Common ear complaints related to TMD are ear congestion, dizziness, hyperacusis, otalgia, and pain around the ear. Eye problems caused by TMD are intermittent blurred or double vision, lacrimation, retroorbital pain caused by a foreshortened sphenomandibularis muscle, pain above the eye referred from the trapezius, and swelling below the eye.
This women had 24/7 constant ear pain for three years. She had been told by multiple doctors, “Sorry, honey; your accident hurt your ear and there is nothing we can do.” I placed Marcaine into the zygomatic fibers of the Masseter and her Otalgia was absent within a minute. This was 1988. TMD treatment has come a long way since then.
Janet Travell knew this many years ago. She was President Kennedy’s physician and she mapped every muscle in the human body and documented that trigger points in any muscle could refer symptoms, pain or dysfunction to other areas. Sixty years later, no one has improved on her original anatomical maps. I was fortunate enough to study under her in the 1980s while she was 88, in a wheelchair, and still teaching.
The statements made here are not my personal feelings. They are all statements of fact based on, not my opinion and my experience, but they are gathered from peer-reviewed journal articles or textbooks. I use them when teaching medical students at Michigan State Osteopathic Medical School and the residents at Henry Ford and St. John Hospitals. Physicians understand this concept—dysfunction does not have to be accompanied by pain, and pain can initiate from a distance away from where the pain is actually felt.
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