111 N. Wabash Ave Suite 2011 • Chicago, IL 60602
Diagnosis of TMJ
"It's not possible that my dizziness
could be caused by my teeth!"
—a 60-year-old businessman
"Coming here is my last hope."
—a 40-year-old nurse
Diagnosis of TMJ is both simple and complex.
This sounds paradoxical, but it isn't. The simple element
is a screening process that can—and should—be
a part of routine examinations of all dental patients. This
simple screening procedure should also be a part of the diagnostic
process for every patient who seeks medical help for headaches
and other symptoms of TMJ.
THE VALUE OF SCREENING
Although the average dental patient is seldom
experiencing TMJ symptoms, a positive finding in the screening
can at times be crucial. Few people who have a positive screening
for TMJ will need the more complex diagnostic procedures or
treatment for the condition. These are usually reserved for
patients who are symptomatic or need sophisticated dental
procedures. But, in a small percentage of people, just knowing
they have a propensity for TMJ problems can save many years
of anguish and perhaps thousands of dollars in fruitless medical
investigation and treatment should they become symptomatic.
A positive TMJ screening simply informs the health care professional
and the patient that the patient is a potential TMJ sufferer.
An example will illustrate the value of TMJ
screening. Recently I received a call from Jim Murray, a former
patient who'd had a positive screening for TMJ. He'd relocated
to Ohio, and a few months before he decided to call me, he'd
begun having regular headaches. "They started out mild,
but now they're severe," he said. "I have a headache
every day, and they're interfering with my life in a serious
way. I can hardly make it through the day at work, let alone
have a normal social life. I can trace the beginning of the
headaches to a skiing accident I had. I was bruised and had
a cracked rib that healed without difficulty, but shortly
after the accident my headaches started. And I remembered
what you told me the first time I saw you for a check-up."
I had told Mr. Murray the same thing I tell
all my patients with a positive finding for TMJ:
You have a tooth-gearing problem. The vast
majority of people do. Chances are you will never have symptoms
of TMJ serious enough to be treated. But if you begin having
regular headaches, neck or shoulder pain, backaches, popping
or clicking in your jaw, numbness of the extremities, or middle-ear
symptoms, then make sure TMJ is considered in the diagnostic
investigation into your problem. In your case TMJ should be
considered one of the primary possibilities, and keeping that
in mind could save you enormous frustration, lengthy bouts
with pain, and money spent in diagnostic procedures.
It's always heartening when a patient remembers
this information. In the case of the injured skier, his memory
of the TMJ screening gave him information about the possible
cause of his pain. He was then able to seek an evaluation.
The examination confirmed that the source of his pain was
TMJ. We worked out an appropriate treatment plan, which ultimately
relieved him of his problem.
Unfortunately, this kind of case is less common
than the patients who see me after seeking help from numerous
medical specialists. One patient with a positive TMJ screening
had forgotten the advice she received. She looked for answers
to her problem of severe headaches for a year before she remembered
to consider an evaluation for TMJ. She'd been hospitalized,
been given multiple batteries of tests, and even had two brain
scans before she thought of TMJ. Once a TMJ evaluation uncovered
the source of her pain, she was on the road back to a normal
life. Within two months she was substantially pain-free; four
months later her treatment was complete.
THE SCREENING PROCESS
It seems difficult to believe that a condition
that causes so many problems can actually be detected in a
matter of seconds. In an initial TMJ screening, patients are
asked if they have experienced any of the common symptoms
of the problem. Regardless of the outcome of the symptom check,
the next step is examination of the external pterygoid muscles
to see whether they are in spasm. This involves applying light
pressure—a few ounces—to the muscle while observing
the patient's responses. The response gives an indication
of whether or not the muscle is in spasm. If it is, the touch
is mildly to severely painful.
Sometimes a patient will show a response but
deny feeling any pain. I often examine people who, while they
appear not to respond, have an unmistakable look of pain in
their eyes. As any person trained in the healing arts knows,
the eyes give away pain. Sometimes people deny any symptoms,
except for an occasional headache, or any discomfort when
pressure is applied to the Lateral pterygoids. My examination
reveals that many of these people do have some indications
of TMJ. But they answer the questions quickly, without thinking
about them, because they sometimes think the questions are
so out of the ordinary for a dental visit. They expect a question
about head, neck, and shoulder pain about as much as they
expect me to ask them about bunions.
Many patients have spasms in the external pterygoid
muscles but have no symptoms at all. These patients may remain
that way for the rest of their lives. The TMJ screening only
evaluates a predisposition to the problem.
Part of the screening procedure is a look at
the motion of the jaw (its gait) to quickly evaluate the gearing
of the teeth. In patients with tooth-gearing problems, the
jaw usually makes a "detour" to the right or left
as it opens and closes. The gait of the jaw gives preliminary
information whether a tooth-gearing problem exists. Still,
many patients have muscle spasms and a tooth-gearing problem
but no symptoms of TMJ.
At this point, the actual screening—taking
only a few minutes—is over. For the vast majority of
patients, a positive response to the TMJ screening yields
important information to be filed away in case it is ever
needed. No further investigation into this problem is required.
Mr. Murray's case was certainly a classic example of how useful
the screening process is.
Remember that if a patient responds positively
to a TMJ screening and later has symptoms similar to those
of the condition, the positive screening does not necessarily
mean that the symptoms are being caused by TMJ. The symptoms
of TMJ are common to many physical and psychological disorders.
Just as it's necessary for physicians to be aware of TMJ,
it is also crucial that dentists not fall into the trap of
believing that all headaches are caused by TMJ. However, it's
been my experience that most symptomatic patients have had
other causes of their pain ruled out before seeking TMJ evaluation.
At what point should a positive screen for
TMJ be followed up with further diagnostic techniques and
evaluation? The answer is twofold. If a patient seeks help
because of symptoms, then a full diagnostic evaluation is
done routinely. If the symptoms come to light in the course
of an interview, then a complete diagnostic evaluation may
also be appropriate. Many patients have symptoms that are
so mild that they don't choose to follow up diagnosis with
treatment. Others are in such intense pain that they are desperate
There are other circumstances where diagnostic
procedures are crucial. Sometimes a positive finding in the
screening can extensively alter a standard dental treatment
plan for a patient. The treatment plan may include treating
TMJ as a primary and vital step even when the patient is not
experiencing symptoms at the time. The best way to illustrate
this is to cite some examples where further investigation
DENTAL WORK AND TMJ
Marianne Williams was referred by another dentist
for extensive dental work. She needed bridges and numerous
crowns. Her TMJ screening was positive; she had a tooth gearing
problem as well as some muscle spasms. Ms. Williams said she
was not experiencing any of the symptoms she'd been asked
about. However, there was a good chance that proceeding with
the needed dental work could worsen the muscle-spasm problem
and cause her to become symptomatic during or after the treatment.
Ms. Williams was advised to address and treat
the TMJ condition first, and then proceed with the bridges
and crowns. All too often, a patient's expensive crowns and
bridges have had to be altered—in some cases destroyed
and re-fabricated—because extensive dental work triggered
For many people with potential TMJ problems,
dental work can trigger TMJ symptoms because treatment requires
a certain amount of manipulation of the jaw. Gearing surfaces
of the teeth may also be changed. The patient may not adapt
to and tolerate the change.
Does this happen 100 percent of the time? Not
at all. But there is no way to predict who will become symptomatic
and who will not. Many patients with the propensity for TMJ
will go through a lifetime of dental treatment, including
dentures in their later years, and never show symptoms of
Ms. Williams wisely decided to address her
TMJ condition first. Her health history contributed to her
decision. In the diagnostic evaluation, she revealed that
although she was not suffering TMJ symptoms at that time,
she had experienced them in the past. When she learned the
symptoms of TMJ, she remembered that five years previously
she had been plagued by frequent and severe neck and shoulder
pain. Upon reflection, she realized the pain had occurred
over a six-month period when she was under unusual stress.
The pain gradually lessened as the stress decreased. She had
correctly attributed her pain to tension, but didn't know
that she was predisposed to 1 MJ and that it was the root
cause of her pain.
It's common for patients to look back into
their own health histories and realize that they had, at another
time, manifested TMJ symptoms. Had Ms. Williams known about
TMJ, she could have addressed the problem, undergone treatment,
and been spared six months of intense pain. Furthermore, had
the bridgework been done prior to TMJ treatment, the problem
might have been re-triggered. At that point she would have
had to undergo treatment for the TMJ and then a repetition
of the dental work. Proceeding with extensive dental work
without addressing the TMJ problems is too big a risk to take.
Occasionally a patient will elect to do just that, but it
PAIN AND TMJ
Sometimes patients go for routine dental care
when, unlike Ms. Williams, they are manifesting TMJ symptoms.
Some are in pain, but they have no idea their problem is related
to their jaws. Often they get treated for the dental problems
and no one ever discovers the TMJ. One case is a particularly
dramatic illustration of how important this is.
Joy Rubin was not in pain when she gave her
history. She had been referred for bridges in her lower jaw
and expressed some surprise at my questions. Also, her neck
movements were restricted; she was unable even to turn her
head from side to side. In response to questions about this
condition, Ms. Rubin revealed a number of things. Her stiff
neck was a permanent condition; it never got better for even
short periods of time. Every time she needed to look anywhere
but straight ahead, she had to turn her whole body.
Ms. Rubin had been suffering with this condition
for six years. It began with an automobile accident in which
she suffered a whiplash injury. She had been to numerous medical
specialists, including internationally known treatment institutions.
She had also been under treatment with naprapaths and chiropractors
but received no relief. She had been told to live with the
condition, and for the previous two years she had become reconciled
to living the rest of her life with restricted movements.
A thorough evaluation indicated TMJ. Ms. Rubin
went home to think about the advice that she receive treatment
before taking care of the bridgework. She needed some time
to make up her mind because her previous treatments for this
"locked neck" had falsely raised her hopes. When
the various treatments didn't help, she became discouraged
and depressed. Ultimately she gave up hope. It's often difficult
for people to believe that a condition they've learned to
live with can be alleviated. They don't want to face the painful
possibility of being disappointed again. Of course, Ms. Rubin
received no guarantees about TMJ treatment.
She decided to take what she called "one
more chance" and see whether her condition could be reversed.
She was taking more of a chance some twelve years ago than
she would be taking today. The treatment protocol was neither
as established nor as predictable years ago as it is now.
Treatment began with the idea that relaxing her neck muscles
could help the situation. The relaxation techniques were successful,
much to Ms. Rubin's delight and relief.
During the diagnostic interview we talk about
all the symptoms related to TMJ, past and present. The interview
is usually quite lengthy. I want as much information as possible
about the patient and the symptom pattern. When do the headaches,
if that is the presenting symptom, occur? Where on the head
are they located? How long do they last? How often does the
patient have a headache? Other symptoms are evaluated in detail
In Ms. Williams' case, her neck and shoulder
pain history was taken in great detail. She had experienced
a period of almost constant pain. Although her primary problem
had occurred in the past, it could happen again at any time.
I try to learn as much about the patient as I can in order
to learn what might trigger the symptoms.
Because Ms. Williams had been under stress
when her symptoms began, she tried to alleviate or manage
the stress with exercise. She found, as do many patients with
TMJ problems, that certain kinds of exercise make the problem
worse. Bicycle riding had been one of Ms. William's favorite
activities. Unfortunately, because of her tendency to clamp
down on the teeth while bike riding, the muscle spasms became
worse, and her neck and shoulders became unbearably sore.
Even when the pain ended, she was afraid to get on a bike
again for fear she would start the pain cycle over again.
EXPERIENCES WITH DIAGNOSIS
Mr. Murray had current daily headaches. Until
he was examined and interviewed extensively, there was no
way of being certain that his new headache problem was TMJ
related. This was true even though he'd had a positive screening
for TMJ some years before.
Mr. Murray's history was straightforward. His
headaches had begun after an accident and seemingly overnight.
The pain always started in his neck and moved up the back
of his head and then to the top of his head and radiated to
the temple region. We sometimes call this the "bathing
cap" headache. His pattern was the same every day. He
woke up with a headache and went to sleep with the pain. Sometimes
he would waken in the night with a clenched jaw. He thought
he was grinding his teeth as well.
In the examination, the slightest pressure
of Mr. Murray's external pterygoid muscles made him almost
jump out of his chair. Sometimes one part of the muscle is
more sensitive, upon examination, than another part. The reactions,
while unpleasant for the patient, help confirm that the symptoms
are related to TMJ.
Mr. Murray came to the office in pain. Many
patients do. Fortunately he decided to come in for a TMJ evaluation
before he began to take narcotic pain relievers suggested
by his physician. He was still coping as best he could with
over-the-counter medications. Those patients who seek help
for intense pain are often emotionally distraught as well.
A few are almost incoherent because of the medication prescribed
for them, and an interview is almost impossible to conduct.
For many, their whole lives revolve around pain and attempting
to cope with it. Sometimes the interview is emotionally as
painful as the physical pain they are experiencing.
A woman named Julia Miller sought treatment
in extreme physical and emotional pain. She was employed as
a computer operator, her third such position in five years.
A few months after starting the first computer job, she began
having severe neck and shoulder pain. The pain became so intense
that she became anxious every day about her ability to perform
her job. Over a five-year period, Ms. Miller had lost two
jobs because the pain interfered with her efficiency. When
she finally landed a third job, she had been able to keep
it only by investing a substantial amount of money in massage
therapy two or three times a week.
Ms. Miller had reached a point in her life where the pain
and anxiety had taken over her daily life—she was literally
terrified of losing her job. She began to cry when she sat
down for the interview and continued to cry after we were
through. Although the muscles in her neck and shoulders were
in painful spasm and she jumped whenever they were touched,
the physical pain was nothing compared to the emotional pain
she was feeling.
Ms. Miller, like most patients who have had
the problem for any length of time, had sought help from many
specialists. After she was unable to find relief, except temporarily
from regular massage, she became depressed and also stopped
talking about her pain to others. She lived alone, and her
life revolved around trying to get through a day at work,
and then relieving the almost unbearable symptoms through
massage and other relaxation techniques. She also had a well-read
library of self-help books on pain.
Over lunch one afternoon, a co-worker began
talking about his headaches and how he had been "cured."
The conversation occurred out of the blue, because Ms. Miller
had never opened up to anyone on her job about her condition.
In fact, she had come to believe that she was the only person
who had ever suffered in this way. Her co-worker listened
sympathetically when she finally decided to open up about
her problem. This man remembered that neck and shoulder pain,
while not his chief complaint, is one of the symptoms he'd
been asked about. He convinced her to make an appointment
for an evaluation. Because she had hidden her problem from
so many people for long, going through the whole story of
her pain was an intense emotional experience.
While Ms. Miller was a high school student,
she had been treated for headaches that had been labelled
as migraines. These headaches disappeared about the time she
began working as a computer operator. Unfortunately, the shoulder
and neck pain developed. While it could be that her earlier
headaches were migraines, she may actually have had undiagnosed
TMJ headaches. In her examination, even though she wasn't
experiencing headaches, the various muscles in her head were
in spasm, along with those in her neck and shoulders. Being
a computer operator had forced her to sit in a chair for hours
at a time, and her posture had been affected. Her symptoms
had exhibited themselves in her neck and shoulders rather
than her head.
A shift in location of symptoms is very common.
The reasons for these travelling or "migrating,"
symptoms are quite logical considering the number of motions
we put our bodies through every day. Our posture varies and
changes as well. In certain people, putting stress on certain
muscles makes them susceptible to spasm. The posture Ms. Miller
assumed during working hours had shifted the spasm pattern
down into her neck and shoulders. She may also have experienced
mild headaches, but because the pain in her shoulders was
so extreme, she didn't notice them.
A STORY WITH A MORAL
Of course, not every person in pain has TMJ.
There are many many reasons for headaches, and detailed evaluation
can sometimes rule out TMJ and lead the way to an accurate
One man whose most troublesome symptom was
recurring intense headaches also had other symptoms that are
classically related to TMJ—facial pain and numbness
in the extremities and face. These symptoms had started some
months after an automobile accident. However, the examination
indicated that the signs did not go along with TMJ. The man
had no tooth-gearing problem, and he was free of muscle spasms
in his head and neck. The combination of symptoms suggested
a neurological problem. He was referred to a neurologist and
urged to look into his problem immediately. After a complete
examination and testing, the neurologist diagnosed a brain
There is a moral to this story: It is important
to be able to differentiate TMJ from other causes of headache
and other symptoms that mimic TMJ. Just as TMJ patients in
pain shouldn't miss out on appropriate treatment for their
problem, neither should my colleagues in the dental profession
and other healing arts treat all headache pain as if it were
related to TMJ.
WHERE TO START
As TMJ becomes more widely known, patients
occasionally see a dentist first, rather than seeking a physical
examination. Marilyn Evans illustrates the shortcomings of
this approach. Ms. Evans was a neighbor and long-time friend
of one of my patients. Because they are friends, Ms. Evans
had heard the "saga" of her neighbor's successful
treatment for TMJ. When she began having headaches once or
twice a week, she thought they could be TMJ-related as well.
Her headaches were severe, and over-the-counter pain killers
didn't help. She also tried some leftover narcotic pain killers
she'd used after unrelated minor surgery. She made an appointment
with me, eager to have her problem solved as her neighbor's
Thorough examination showed that Ms. Evans
had none of the diagnostic pointers to TMJ. When she described
her headaches, they sounded like classic migraines—vision
changes, nausea, a sense of flashing light. She was disappointed
to hear the suggestion that she see a neurologist, who could
help her with her specific problem.
EXAMINATION OF THE JOINT
A TMJ evaluation also includes an examination
of the temporomandibular joint itself.
The joint is palpated; that is, touched or
felt in such a way as to determine size, sensitivity, shape,
motion, etc. We do this on the outside of the face in front
of the ears, and through the ear canal while the patient opens
and closes his or her mouth. There should be no popping or
clicking. The patient indicates whether he or she is experiencing
pain when opening and closing the mouth in this way. I always
listen to the joint through a stethoscope as the mouth opens
and closes; this gives an idea of the joint's overall health.
X-rays of the joint are another part of the
evaluation. There's seldom anything unusual in the X- rays,
but they can show dental problems, tumors, evidence of old
injuries, and arthritis. A mass on an X-ray would signal a
condition that needs attention from other specialists.
The jaw is also manipulated to determine the
discrepancy between the way the teeth do gear and where they
would gear if the existing teeth did not pull the jaw out
of alignment. Fillings and other dental work are examined
to see how they contribute to the problem.
A detailed interview and an oral examination
are the core of the evaluation. The X-rays merely screen the
patient for rare problems that may be contributing to the
TMJ. The examination confirms, denies, or quantifies impressions
formed during the interview process.
Headaches are the most common symptom produced
as the result of the muscle spasms caused by the tooth-gearing
problem; by no means are they the only one. You may have headaches
and none of the other symptoms, or all of the others and no
headaches at all. You may have one or three or five of the
others without having connected them. It's important to examine
all the common symptom groups found in people with TMJ problems,
and explain and discuss how and why they occur in susceptible