Stay Well: I went to the GP with jaw pain and was told I may have TMD. What is it and how can I fix it?
Around half a million Irish people suffer from what is called ‘temporomandibular disorder’, with women affected at a higher rate than men. So why does it happen and what can be done about it?
Discomfort, clicking and pain in the jaw can be at best a nuisance, and at worst debilitating. People who suffer from temporomandibular disorder (TMD), which refers to a variety of conditions that affect the jaw area, can experience stress, chronic pain and poor sleep.
It’s estimated that around 550,000 in Ireland have some form of TMD, and it affects women at a higher rate than men. Why does TMD occur, and how can it be managed and treated?
What exactly is TMD and what causes it?
TMD is an umbrella term for a variety of conditions that affect the temporomandibular joint (TMJ) – the hinge joint connecting the jawbone to the skull – and the surrounding muscles. This disorder can lead to pain and difficulty with jaw movement. There are a number of potential causes of TMJ conditions.
“Excessive pressure to the jaw, i.e. trauma, aggressive clenching or grinding; an overly tight camogie helmet; or frequent flute practice may overload the TMJ or masticatory muscles contributing to a temporomandibular disorder,” explains Dr Eamonn Murphy, orofacial pain specialist and founder of Jawpain.ie.
“It is not a single condition but a collection of related muscle and joint conditions, which may occur in combination or isolation.”
While TMDs are relatively common, there is some confusion and misunderstanding surrounding these conditions.
“Despite popular belief, it is not as simple as a clenching and grinding habit triggering TMD,” says Kim Cusack, chartered physiotherapist and owner of Faces Physiotherapy. “While this is one factor, recent research has shown that in otherwise healthy individuals clenching and grinding alone is not sufficient to bring on the pain associated with TMD.”
A combination of lifestyle, hormonal and genetic factors are the main contributors to jaw pain and TMD. “Environmental factors, like stress and poor sleep, as well as excessive jaw activity (known as parafunctions) interact to initiate jaw pain and/or jaw-related headache,” says Cusack.
“Minor or major trauma to the area, as well as indirect trauma (as in whiplash) can also trigger TMD. Hormonal factors and genetic factors are also thought to contribute to the overall likelihood of developing TMD but the research is still uncovering the exact mechanisms at play.”
Who does it affect?
While anyone can experience TMD, it is most common in young adults, particularly women.
“TMDs are common but thankfully, most are mild in nature. The peak incidence is between 25 and 45 years. Women are affected three to four times more commonly than men,” says Murphy.
It’s not clear why women are more affected, but it’s likely that physical and lifestyle factors play a part. “TMDs are multifactorial in origin and there is no single reason why they are more common in females. Various factors such as hormonal fluctuations, anatomical and behavioural differences play a role…Stress induced jaw clenching and tooth grinding are commonly associated with TMDs,” Murphy adds.
What are the symptoms of TMD?
There are more than 20 different types of TMD, and symptoms vary widely according to the condition and individual.
“TMD presents differently between people, with symptoms varying considerably in intensity and duration. Some people experience mild, intermittent discomfort, while others experience severe, persistent pain that significantly affects their quality of life. It’s also common for symptoms to fluctuate over time, appearing and disappearing in cycles. In a minority of cases it can become constant, chronic and in need of multidisciplinary care,” says Cusack.
Jaw pain is a common symptom of TMD conditions. “Many TMDs are associated with jaw pain. This pain can be localised or more generalised,” says Murphy. “A localised TMD will commonly affect the jaw joint in front of the ear and it may
Jaw-clenching is another common feature of TMD, which can lead to wider issues
masquerade as ear pain. Other TMDs will have a more diffuse presentation manifesting as headache or facial pain.”
Jaw-clenching is another common feature of TMD, which can lead to wider issues. “If someone is regularly clenching their jaw, this may contribute to additional jaw symptoms such as jaw tension, fatigue, temporal headaches, jaw muscle hypertrophy, tooth sensitivity, tooth wear and less commonly fractured teeth or non vital teeth,” says Murphy.
Stress can be a feature of chronic jaw pain, and living with this condition can negatively affect mental health. “Stress can have a significant impact on TMD. Clenching of the jaw is often associated with activation of the sympathetic nervous system, also known as the fight or flight response. This system is activated as a form of threat perception, so helping to calm it down is a key therapeutic aim,” says psychologist Dr John Francis Leader.
“Unfortunately clenching [the jaw] can create pain, discomfort and more tension, leading to a feedback loop. And often this can happen unconsciously, including during sleep.”
How is TMD diagnosed?
Most TMDs are diagnosed following a comprehensive clinical evaluation of jaw joint mechanics, the surrounding muscles, jaw behaviours, and any psychosocial factors.
“It is also important to distinguish jaw disorders that are recent onset/acute from those jaw disorders which are chronic/longstanding. Chronic jaw pain is associated with higher levels of disability and distress and may not respond to the treatments commonly prescribed for acute jaw pain,” says Murphy.
Because of the similarity of symptoms, TMDs can sometimes be mistaken for other conditions, which need to be ruled out in diagnosis.
“Many disorders of the TMJ will manifest with ear or tooth pain. It is important to consider other orofacial pain conditions in the differential diagnosis of ‘suspected’ TMDs,” says Murphy. “For example, when patients present with recurrent TMD symptoms, it is important to rule out dental pathology, ear infections, oral cancers, sinus disease and less commonly trigeminal neuralgia.”
What are the treatment options?
Depending on the type of condition, there are several treatment options that may be recommended.
“There is no ‘one size fits all’ approach to treatment,” says Murphy. “The vast majority of TMD patients will respond to conservative behavioural management incorporating jaw posture training and a jaw stretching programme. It is important not to overfocus on jaw symptoms, but to understand what is causing these jaw symptoms.”
In mild cases, patients can manage the condition at home. “Painless clicking jaw joints usually require very little management – patients are simply told to avoid behaviours that exacerbate this condition and are given simple tools to avoid it progressing to a painful or functional problem which happens in the minority,” says Cusack.
“Muscular issues are usually managed well with a supported self-management programme with or without physiotherapy depending on the severity.” For more complex presentations a multidisciplinary approach is necessary, including the GP, dental specialists, maxillofacial surgeons, physiotherapy and psychology.
Most treatment programmes will consist of a combination of behavioural therapy, anti-inflammatory or muscle relaxing medication, jaw splints, botox or steroid injections and less commonly surgery.
Can psychological therapies help?
In some cases, psychological support for stress relief and pain management may be recommended. A recent study published in the Journal of Oral Rehabilitation involving 53 women with jaw pain showed that regularly practicing mindfulness, a meditation technique involving focus and full attention, can help reduce pain sensitivity and improve emotional regulation. A medical assessment can help to address or rule out any underlying physiological causes of TMD. “Therapeutic supports then tend to either be direct or indirect, with cognitive behavioural therapy (CBT) and mindfulness-based cognitive therapy (MBCT) being popular and effective approaches,” says Dr Leader.
“Direct approaches often involve learning to actively relax the relevant muscles, to notice tension and respond to it better, and to recognise the contexts when this happens so these can be better interpreted and stress managed in more effective ways. Pain management work can also play a role when there is an underlying condition.”
“Indirect approaches tend to focus on other factors that can cause stress, even if not directly related to jaw tension. Like the ‘straw that breaks the camel’s back’ expression – sometimes a number of non-related things can accumulate to create tension, and clenching can be used as a way of trying to release that.”
While living with TMD can be challenging, in most cases, symptoms can be managed well.
“Most TMDs can be managed successfully, reducing pain levels and restoring function. A minority become chronic and these require careful management,” says Murphy.
“A dentist will often liaise with other healthcare providers such as the GP, physiotherapist or pain psychologist to-co manage this small group of patients.”