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Questions and Answers

Here are questions people have asked me over and over again. It's my hope that the answers will clarify your understanding of TMJ.

Is there such a thing as a TMJ profile or a typical TMJ sufferer?
This is a common question, perhaps intended to narrow the field of sufferers. The typical TMJ sufferer usually has headaches. Beyond this, it's impossible to be specific.

Is it true that the majority of people who suffer from the symptoms of TMJ, and headaches in general, are women?
It is true that in the popular literature that discusses headaches, the majority of sufferers are women. The typical headache sufferer depicted in advertisements for headache pain relievers is usually a woman. However, headaches and other symptoms of TMJ seem to be fairly evenly distributed between the sexes. The majority of patients in my practice are women, but the majority of patients in almost all dental or medical practices tend to be women.

Women seem to know they need regular medical visits such as gynecological checkups and breast exams, and they make sure they get them. Women also tend to go to their dentists for routine checkups. In my experience, men more often wait until something is wrong. To treat dental problems that, because of neglect, have become emergencies, I see many more men than women.

There is still a kind of macho image that many men feel they must live up to. Men will deny pain more often than women. It's as if they see pain as something to be ashamed of.

I have heard of women complaining of a backache—a possible symptom of TMJ—and when no cause is found, they are labeled neurotic. Have you heard of men who suffer from backaches? What we usually hear is, "I threw my back out." (He might also attribute it to doing something "macho" like lifting a heavy object.) There is still pressure on men to disassociate themselves from conditions that have for too long been linked with the so-called weaker sex.

Does any one age group appear to be affected by TMJ problems more than others?
I've treated patients as young as ten and as old as seventyeight. However, the bulk of my patients are in the prime of life, ages thirty to fifty. People wonder why, if a toothgearing problem exists, symptoms didn't begin in the stressful period of adolescence. While it's unknown why this disorder seems to strike in the middle years, certain diseases and disorders are common in childhood, others are common in older people. Perhaps TMJ will be found to be a disorder common to those in their prime. Perhaps it is simply related to the changes in the topography of the teeth—wearing down, more tooth replacement, and so forth. It may also be that the most active years are when we're more susceptible to traumas of the head and neck, which can trigger the problem. We can only hope that more research will reveal the answer to this question.

Do certain racial or ethnic groups tend to have higher incidence of TMJ than others?
Certainly none that we know of. TMJ appears to be about evenly distributed.

Is it common to have only middle-ear symptoms, but no headaches, neck stiffness, or any other common symptoms?
This isn't common, but it happens occasionally. If you are told that nothing is wrong with your ears, then TMJ would be a logical condition to investigate. But when starting the search for help, those with only middle-ear symptoms should begin with medical specialists, and TMJ should be among the last conditions to investigate.

My doctor says TMJ doesn't exist. Is this a common attitude among physicians?
It is more common than it should be, but few physicians deny the existence of TMJ. Rather, they might deny the high incidence of the condition, and doubt that it could be the major cause of headaches. Physicians have said it was hard to believe that all that pain could be caused by muscle spasms, especially small muscles like the external pterygoids.

Once TMJ is included on the list of possible causes for headaches, and training programs for all the healing arts are changed, patients will begin to be screened in physicians' offices for this problem. Physicians can be TMJ sufferers too, and if you ask such physicians whether they believe in the condition, you will hear no denials. Anyone who has ever been afflicted and then relieved of chronic pain caused by TMJ becomes a fast believer.

My dentist says the label of TMJ is being put on too many people, and that it's actually quite rare. Why is there such a vast difference of opinion?
Dentists not trained in TMJ might hear this message from someone they respect. Because they respect this individual, they may take the message seriously and absorb it as if it were truth. A dentist may hear the stories of a dentist who began to treat TMJ but had poor results. Many times, when treatment for TMJ fails, a judgment will be made that the condition probably wasn't TMJ in the first place. Knowledge of and belief in any concept often have more to do with exposure, training, and experience, either one's own or that of colleagues, than with the actual existence of a particular problem.

One dentist said I have TMJ. Another said I don't. Should I seek another opinion? Could I be a borderline case?
Dentists vary in their knowledge of the field. A "borderline case" is one in which the diagnosis is in question. Perhaps the patient isn't symptomatic, or suffers from symptoms mild enough that treatment isn't indicated at that time. Whenever there is a question it is always best to seek a second knowledgeable opinion.

I believe I have TMJ. I suffer from all the symptoms, and my dentist says I have a tooth-gearing problem. But I've spent a lot of time and money in pain clinics learning how to rise above the pain and live with it. I'm afraid to begin a new kind of treatment for fear that I'll lose the ability to cope with pain. Does this make sense?
It is certainly understandable that people are concerned about repeated disappointments in therapy. At times, learning to cope with pain seems like the most comfortable solution. However, in a case like this one, the person should have an evaluation for TMJ by a dentist who has a track record of successful treatment. If such treatment is available, the patient should go ahead with it. If someone had put a nail in your arm ten years ago and no one knew how to remove the nail, would you still keep the nail there when you have been shown that new nail-removing techniques have become available? Most people want to get rid of pain, not just cope with it. The techniques pain clinics use are wonderful in situations where no cause or cure can be found. There are other pain syndromes besides TMJ, and these clinics have helped many people live more normal lives.

I once had a bout with many of the symptoms of TMJ. It lasted about six months, and then it gradually went away and never came back. If I have the predisposition to TMJ, am I a "condition waiting to happen"?
You probably are. When you became symptomatic, your threshold or tolerance dropped, and when it went up, the symptoms went away. Any person with such an episode should keep TMJ in mind if these symptoms ever recur, or be mindful of the problem if restorative dentistry is ever needed. Remember, extensive dental work provided without knowledge of this problem can trigger TMJ.

Why do some people with a tooth-gearing problem become symptomatic, while others with the same problem remain symptom-free?
We don't know why some people are susceptible and others are not. We don't know why some people seem to be more susceptible to having muscles in the head and neck go into spasm. In the symptomatic person, we aren't sure why the susceptibility varies from week to week, day to day, and even year to year. We don't know why the tolerance threshold drops and symptoms occur. The severity of the tooth gearing problem seems to have little to do with the severity of symptoms.

My therapist says I grind my teeth at night because of psychological conflicts. He says that when I work out my problems, my aching jaws and headaches will go away. If I have a tooth-gearing problem, how will correcting psychological problems help?
In a broad sense, solving psychological problems has little effect on TMJ. Any effect is over a very long time, and the tooth-gearing problem and, therefore, the potential to trigger the symptoms remains. We know that grinding or gnashing of teeth is one way humans—and other animals— manifest stress. We can see this when a dog feels threatened or is protecting its territory. So teeth grinding, or bruxism, as it is called, may be a psychological phenomenom. However, the physiological problem—the incorrect gearing of the teeth—is not. TMJ treatment addresses the gearing problem.

Psychotherapy is recommended when a patient is under extreme stress and is handling it poorly, or when underlying problems are preventing a person from functioning normally. Since TMJ is a physiological problem that is in no way brought on by psychological problems, it is most important to correct the tooth-gearing problem. Therapy can't correct a mechanical problem like TMJ.

I see a chiropractor regularly, and my back problems have greatly improved. However, while my headaches are better right after a visit, they always come back. Why?
People with back, neck, and shoulder problems and headaches commonly see practitioners such as massage therapists, osteopaths, naprapaths, and chiropractors. They often receive symptomatic relief for certain problems such as headaches, but nothing is done to permanently correct the tooth-gearing problem. They receive temporary relief because the therapies relax the muscles temporarily and break the spasms. However, because the causative reason has not been addressed, the spasms quickly start again. TMJ treatment corrects the problem that triggers the cycle of spasm and pain.

You seem to disapprove of drugs for anything. Are you against using drugs in health care in general?
It often must appear that I am against using pain relieving drugs in general because I don't use them in treating TMJ. Actually, pain relievers can be valuable in numerous situations, including dentistry. I wouldn't want to drill teeth without using anesthesia. And medications of all kinds make modern medical care possible. What is inappropriate is the use of drugs in place of finding a reason for pain, for example, as the only therapy for chronic headaches when TMJ hasn't been explored. Too many patients are barely able to get through a simple interview because their bodies and minds are numbed with medication. Very often, the pain wasn't numbed, but the patient had lost the ability to care about it—or anything else in life. Sometimes patients don't even care that they don't care. This is the kind of drug therapy I'm opposed to.

I have dentures, but I also have TMJ symptoms. How can I have a tooth-gearing problem if I don't have my own teeth?
Many of my patients have dentures. A few have the dentures in the first place because they were told it would cure their TMJ. Unfortunately, removal of the teeth doesn't break the muscle spasms. If the spasms are present when the dentures are fabricated, they will be made in the same pattern as the original teeth, which caused the problem in the first place. TMJ treatment should break the muscle spasms and allow the jaw to reposition itself before adjustments are made to the dentures or new ones fabricated. A symptomatic patient should not have all his or her teeth removed as an initial treatment for TMJ. It rarely, if ever, corrects the problem, leaving the patient a "dental cripple."

If pain medications are rarely effective in treating TMJ patients, why do so many patients continue to take them?
People in chronic pain are frightened and depressed. They may at times feel as if they would try anything to help themselves. Sometimes the medications make them care about or notice the pain a little less than without them.

If I seek help for TMJ, I may need help with weaning myself from the drugs I have been taking for ten years. Is this often a difficult process for TMJ patients?
In general, I haven't found this to be a difficult problem. Most of my patients are more psychologically addicted than physically addicted. When they no longer have pain, they are usually glad to break the dependency. However, in some cases where the addiction is physical, or where dependency is established, patients are referred to physicians who can help them with this part of treatment. This is seldom a difficult phase of treatment.

Does TMJ run in families?
It is not documented, as it is for migraine, that TMJ runs in families. However, about 80 percent of the population has the predisposition for TMJ, and therefore it would appear logical that a familial connection will be found.

I have a very sensitive gag reflex, and I can't stand to have any foreign objects in my mouth. Would a nonremovable splint be appropriate in a case like mine?
In a case such as yours, I would generally use a nonremovable splint. However, using this type of splint involves slightly more risk and is much more costly.

I have migraines that are manageable with medications. I also have low blood sugar and often get headaches when I don't watch my diet. I also have premenstrual headaches and appear to be chemically sensitive. But, no matter what I change in my lifestyle, I still end up with headaches that seem to come and go for no reason. How would I find out if some of these headaches are TMJ related?
A TMJ evaluation would indicate whether you have a predisposition to the problem. There well may be a TMJ component, as it's not unusual to have numerous types of headache triggers. The TMJ treatment is like peeling away layers of an onion. When the TMJ component is removed, the patient can continue to evaluate other reasons for the pain. Often, once the TMJ-related headaches are gone, the total number of headaches from other causes may be significantly reduced.

My symptoms began after I was injured in an automobile accident. I was once told that I have a predisposition to TMJ. Is it possible that my symptoms would never have been triggered if I hadn't been in that accident?
Yes. Many people go through an entire lifetime with a predisposition to TMJ and never become symptomatic. However, trauma can jerk or pull the muscles, creating a situation where it is easy for them to go into spasm. Again, we do not know why the majority of people with a predisposition to TMJ will never become symptomatic. But we do know that injury often triggers the symptoms.

My daughter's headaches began after she had orthodontic treatment. Why?
Teeth may not gear properly within the requirements of the jaw for many reasons—nature, the way the jaw grows, the way a person sleeps, dental work, injury, orthodontics, and dentures. If the teeth don't gear properly, the patient is always subject to TMJ. Sometimes orthodontics, as in this case, will create a gearing problem. Sometimes orthodontics are part of Phase II treatment, usually to get the teeth closer to correct gearing, so we can do an equilibration to complete the proper gearing on a minute level.

Does bruxism automatically indicate TMJ?
No. Bruxism is the body's attempt to even out discrepancies in the teeth. The basic gearing problem may create the muscle spasms, and it may create bruxing. Not all people with a gearing problem brux, and not all people with a gearing problem experience painful muscle spasms. We don't know why certain people will begin to brux, and we don't know why this bruxing will trigger painful symptoms. So, not all people who brux will have TMJ symptoms.

Is bruxing the same as a gearing problem?
Bruxing, or tooth grinding, is the result of a gearing problem in certain susceptible people. Often, the teeth that are causing the interference are avoided, and the other teeth are worn down. It's also important to remember that a person with a severe gearing problem may or may not have TMJ symptoms, and may or may not brux. Bruxism is both a cause and a symptom of the problem.

Will equilibration damage or weaken the teeth?
Equilibration on natural teeth most often involves working on the elevations of the teeth. This is advantageous because the enamel coating is usually thicker on the elevated portions of the teeth, and thinner in the "pits." Therefore equilibration rarely damages or weakens a tooth. Occasionally a patient will report increased sensitivity in a tooth that has been worked on. Whenever possible, we try to work within and on the fillings, inlays, and crowns. Sometimes we damage these and then must go in and replace them, However, there is seldom damage to the structure of a healthy natural tooth.

Will I be worse off if the TMJ treatment doesn't work?
One of the advantages of Phase I treatment, as described in this book, is that it can be stopped at any time, usually without any alterations in the patient's mouth. The patient can be left in the same condition as before treatment started. In this sense, a patient is certainly not worse off.

Unfortunately, many people seek TMJ treatment after having had orthodontia, surgery, or equilibrations before their symptoms were relieved. The rationale is that the alterations are needed in order for symptoms to be relieved. This is faulty thinking for the vast majority of cases. Until the jaw has relaxed into its normal position and the muscles are out of spasm, correcting the tooth-gearing problem is chancy. Some people luck out, and their symptoms go away when definitive treatment is done first, but the chances are slim.

I had mysterious tooth pain that was treated with several root canals. I began grinding my teeth after the work was done. Did I develop a tooth-gearing problem?
It is entirely possible that a tooth-gearing problem caused the tooth pain in the first place. On the other hand, you may have had solid reasons to have the root canals done—the teeth may have actually been dying. Once the root canals were done, you may have started to grind unconsciously in order to correct a gearing problem exacerbated or possibly even created by the dental work. It's impossible to look back and gauge the exact sequence of events. People with undiagnosable tooth pain or a bruxing habit should have TMJ screening.

I have had several bouts with TMJ symptoms, and have had TMJ diagnosed by two dentists. The treatment for my symptoms has been physical therapy. It has been quite effective, and whenever my symptoms flare up, I go for treatments. Is this maintenance therapy? If so, what's wrong with it?
Since TMJ has been diagnosed twice, we'll assume that you indeed have the condition. The periodic treatments you have sound like maintenance therapies in that they help you in the short run, but after a period of time the symptoms return, sending you back to the physical therapist. There is nothing wrong with this in and of itself. If this were the only solution to your problem, then it would be just fine, and if you were in severe pain, a true lifesaver. However, it is possible that you could be helped permanently, that your symptoms could go away and not return. The underlying problem can be corrected in the vast majority of cases. In the long run I don't see that permanent treatment is any more costly in money, lost time, and personal frustration than maintenance therapies. However, seeking a permanent solution for TMJ is a personal choice, and if you feel satisfied with the care you are getting, then by all means, continue it.

I have ground my teeth down to about half their original size by bruxing. How would you accomplish treatment in a case like mine?
Phase I of treatment would be the standard therapy described in this book. Phase II would involve correcting the tooth-gearing problem permanently, and if the teeth are severely worn down, it would most likely include reconstructive dentistry. We would need to rebuild what we call the "vertical dimension," the distance between the chin and the nose, which is determined by the length of the teeth when the jaw is closed. Remember that the jaw is basically a hinge and can be stopped in any position. People who have no teeth and do not wear dentures have a much shorter distance between the chin and the nose than those with teeth of normal size for them. When the teeth are worn down, we estimate the correct vertical dimension and build up the teeth, using plastic crowns, until we have established the most normal gearing pattern possible. The temporary crowns are then replaced with permanent ones.

My mother began having neck and shoulder problems at about age seventy. Lately she has been complaining of headaches, too. Is it common for a person to become symptomatic at such a late time of life? Has she had TMJ all her life, but is just symptomatic now?
There is no way to say for sure that your mother's headaches and other symptoms are caused by TMJ in the first place. It is important to begin by ruling out all other reasons for the pain. If no other reason is found for the symptoms, then TMJ would be a logical condition to investigate.

Only rarely do patients seek a TMJ evaluation after becoming symptomatic in their later years. In these few patients, it is likely that dental work has triggered the onset of symptoms. Often people have spent years wearing their teeth down, have old fillings, or have just become denture wearers for the first time. There's no way of knowing whether they were free of TMJ before their severe symptoms started. Because certain kinds of complaints—headaches, stiff shoulders, neck aches—are considered normal, a person won't even report them unless they are debilitating or beginning to be a regular occurrence.

Older people are more likely to have true joint derangement than younger people. Arthritis in the joint and problems with the disc aren't unusual either in older people. After all, an older person has spent years using his or her jaws. No matter what the signs and symptoms, it should always be determined whether the muscles are in spasm before assuming that surgery is the answer for pain around the joint.

I recently visited a headache clinic where I was given many tests and evaluations. However, TMJ was not considered. Would you recommend that TMJ be considered before I start other treatment?
Absolutely! You may or may not have TMJ. It is important to have TMJ included in any evaluation for the cause of headaches. Eventually, TMJ will be on the list of possible, and common, reasons for headaches. It is possible that you have more than one kind of headache. It is also possible that treatment suggested for you is symptomatic treatment, not a plan that treats the cause of the headaches you are experiencing. Any clinic that specializes in headaches should consider all causes. That can be said unequivocally.

Are you against people with TMJ taking stress-management courses, or learning meditation, or having regular massages? Aren't these things good for all people, regardless of whether they have a pain syndrome?
The things you mention are definitely good for people whether or not they have TMJ, migraines, high blood pressure, or even a bad cold. There is absolutely nothing wrong with any of these courses, techniques, or philosophies. People who have absolutely no symptoms of any disease or disorder can benefit from stress management, massage, and similar care. Many people find they are more productive when they schedule time for relaxation, play, spiritual growth, and exercise. Patients who are taking care of themselves in many ways often reenter normal life much more easily than those who lack hobbies, social lives, satisfying exercise programs, or even well- balanced diets.

What is disturbing is that so many people have been lured into taking up many of these practices as a way to manage TMJ. Sometimes the management therapies work in the short run. Sometimes they make a semblance of normal life possible for people who would otherwise walk around in severe pain practically every minute of the day. These therapies can't cure TMJ. TMJ is physiologically based; it is a tooth-gearing problem that causes muscle spasms in a susceptible person. No amount of relaxation therapy can correct a tooth-gearing problem.

The patients described in this book who have maintained a life, of sorts, by using these techniques were doing the best they could with the information they had. But when a patient seeks help for this problem and talks about life based on self-help, it is clear that, when carried to extremes, this life is stressful in itself.

When patients watch their diets so scrupulously because of their "allergies" that they can't go to restaurants with friends, when they are so afraid of their "hypoglycemia" that they feel obligated to carry food around with them and panic if they don't have it at the "right" time, or when they won't stay out past midnight on a Saturday night because it doesn't fit into their "program," then they are slaves to the stress management, diet, or whatever is supposed to be helping. them.

People who have never lived with pain probably think that those who live this way are rigid to excess. The people who live this way usually think so, too. Most people want to live within the mainstream of normal life.

When they are treated and their symptoms are gone, many patients keep some of the programs that have helped them. And why not? The programs are part of a healthful life that no health practitioner would discourage. But these people are also free to let go of practices they don't like or have observed or practiced to extremes.

I've been told my back pain is caused by my stressful lifestyle and that a certain amount of back pain is normal. I get occasional headaches, sometimes with the back pain and sometimes without it. Does this sound like TMJ?
An evaluation for TMJ is in order. The diagnosis implies that there is no systemic or structural reason for the pain. If TMJ is found to exist, treatment may eliminate spasms in the back muscles by treating other muscles in the chain.

Is TMJ treatment the same for all patients regardless of their symptoms? Is it true that patients with ear symptoms are treated with the same techniques as those with shoulder or back pain?
This is correct. TMJ treatment involves treating muscles in the head—specifically the external pterygoids.. Remember: I don't treat "headaches" or "middle-ear problems." As a dentist, I treat tooth- gearing problems and muscle spasms. And as a dentist, I don't treat back muscles specifically. The key muscles involved in most of the symptoms of TMJ are located in the mouth, an area that dentists can legitimately treat. This is important because patients shouldn't say they went to a dentist to have their bad backs treated. They went to a dentist to have the tooth gearing problem, which caused their symptoms, corrected. The relief of these other problems happens in response to what I do with these key muscles.

If muscle-contraction headaches are the most common type of headache, why has so little research been done to find causes and treatment?

Headaches in general have not been the focus of large amounts of research. This is largely because headaches in and of themselves are not life-threatening and are considered normal. And since most people have headaches at least once in a while, headaches are considered a manageable disorder. Vascular headaches have been considered more "glamorous" than muscle-contraction headaches, and what research has been done has usually been concentrated on the "migraine-type" headache.

If research were to be done on TMJ headaches, it would be logical to try to discover what makes people susceptible to muscle spasms. If we knew this, we would be able to discover why some people with tooth-gearing problems never become symptomatic and why others do.

Are there any rare symptoms of TMJ?
Occasionally a patient will talk about having very dry eyes. It is rare enough not to be included in the list of major, or common, symptoms. Some people mention just the opposite—eyes that tear very easily. A few people believe they have sinus problems because they get a stuffy nose along with their headaches. When the tooth-gearing problem is gone, many people who reported the stuffy-nose symptom often never get any headaches again. Thus, the headaches were probably not sinus headaches, but rather a reaction some people have to TMJ headaches.

I started wearing an athletic mouth guard when I jog, and my symptoms have improved. Should I seek treatment anyway?
You should certainly have an evaluation for TMJ. Whether you need treatment depends on how severe the symptoms are and how you feel your life is affected. Some athletes find their symptoms are worse with the mouth guard. There isn't any way to predict who will get worse or better with mouth guards.

My doctor says TMJ is just another fad disease, and interest in it will die in a year or two. How would you respond ?
I would agree that interest in TMJ is high right now. Many people who had no idea why they were in pain are discovering the true answer. However, the disease is certainly not a fad. It's been around a long time, most likely ever since humans started to walk around on two legs. As more and more people begin to get appropriate treatment, and the "horror stories" on the way to diagnosis become fewer, then public interest will drop. I certainly hope so, because that will mean more people are getting proper treatment for the disorder.