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Tooth Grinding and Facial Pain
Psychotherapy has helped me enormously,
but I still grind away every night.
—a 25-year-old dietitian
I sometimes think the whole roomful of
people can hear my jaw pop.
—a 36-year-old actor
Grinding teeth and pain in the jaw, joint,
teeth, and face often occur together. They may or may not
occur with other TMJ symptoms such as headaches or neck stiffness.
When the cause of these symptoms is unknown or incorrectly
diagnosed, patients can be subjected to various treatments
that seldom relieve the problems.
Bruxism is the medical name for grinding the
teeth. Also, although few people associate it with bruxism,
clenching the teeth is included in the medical definition.
Clenching teeth is a natural response to stress in many animals,
including humans. Bruxism can be directly related to TMJ,
either as a trigger for the spasms or as a result of the discomfort.
Even though bruxism can be destructive to the
teeth, it is not abnormal in all situations. In children it
is not only natural for some tooth grinding to occur, it is
desirable. The teeth in a child's mouth often fit together
poorly, and bruxing is necessary to refine the gearing parts
of the teeth into a more normal scheme.
Typically, newly erupted front teeth have three
bumps, called mamelons. In adults, the mamelons are rarely
visible, because they have been worn off in the childhood
grinding process. The only adults with mamelons have an "open
bite," which means that the front teeth don't touch each
other, and the wearing off of the mamelons doesn't take place.
Parents usually needn't worry if their children
are grinding their teeth, even if the noise made by the bruxing
keeps the entire household up at night. Any potential damage
from the bruxing should show up in normal dental visits. As
the child matures, the excessive bruxing usually disappears.
Later in life, bruxing may become a way of
getting rid of tension, anxiety, or nervousness. (It still
can keep a household awake all night, while the sleeping person
grinds away.) During waking hours, people relieve stress by
clenching more than by grinding. A tooth-gearing problem may
act as a trigger for the bruxing, which can result in muscle
spasms in the Lateral pterygoids and, therefore, may lead
to painful symptoms.
In adults, bruxing can also damage the teeth
and the supporting structures as well as produce painful symptoms.
People with abnormal gearing of the teeth are unconsciously
trying to grind away what doesn't fit well in their mouths.
Unfortunately, the person rarely grinds in the primary area,
that is, where the teeth conflict the most. Rather they shift
to other areas and grind those teeth out of proper gearing.
This happens because teeth that do not gear correctly are
neurologically sensitive. This sensitivity may not produce
pain, however. The body protects itself in ways the person
is not conscious of. This protective mechanism will lead the
person to grind elsewhere in the mouth. A dentist can observe
that some patients have ground their teeth just about everywhere
except where the primary interference exists.
Ellen Rogers was referred by a psychiatrist
because of intermittent but severe headaches. She had also
been grinding her teeth for so long that they were about half
the height of normal teeth. She is by no means the only patient
treated for TMJ whose teeth looked like tiny stubs as a result
of bruxing. Ms. Rogers had a severe tooth-gearing problem
and a full array of other symptoms, including neck pain, vertigo,
and pain around her ears.
At her examination, she displayed a device
she'd been using at night, similar to an athletic mouth guard.
This device makes sense in that it keeps the teeth apart and
prevents further damage to them. However, the mouth guard
can hold the jaw in an unnatural and arbitrary position, which
can then trigger further muscle spasms and TMJ symptoms.
Mouth guards are not recommended for TMJ treatment
simply because the jaw isn't set in a natural position. Sometimes
the patient gets lucky, and this arbitrary position may be
proper for the jaw. In those few cases, symptoms will subside.
But for far more patients, symptoms are exacerbated. Several
patients have reported more severe morning headaches after
using mouth guards than before using them.
Ms. Rogers miraculously didn't have tooth pain
along with the physical damage to the teeth, probably because
the wear had taken place over a long period of time. Sometimes
the mouth will wear itself into a position that the body can
At other times, bruxism can go along with un-diagnosable
tooth pain, which is another symptom of TMJ. While this isn't
always the case, people who are aware that they sometimes
grind their teeth at night shouldn't be surprised if they
have toothaches or jaw pain for which no apparent cause can
There are numerous reasons for tooth pain,
including decay, injury, a dying nerve in the tooth, an abscess,
or a sinus infection. The reasons for tooth pain in a TMJ
patient can be more complicated. Because a tooth has nerve
material and tissue, it can become inflamed and swollen. Pain
and sensitivity to cold are also early symptoms of a dying
tooth. A dentist examining a patient will listen to the patient,
X-ray the tooth, and tap the tooth with an instrument. Even
though nothing is visible to indicate it, the symptoms point
to a dying tooth. While other causes of pain are easily diagnosed
by a dentist or a physician, in patients with toothaches caused
by TMJ, the diagnostic process can be baffling.
A patient once came to me for a routine check-up,
and before I'd even had a chance to examine her, she told
me that the previous year she'd had five root canals. When
I questioned her further, she said that the root canal series
had begun when one tooth caused her a great deal of pain.
There was no decay or injury to the tooth, and it was eventually
concluded that the tooth must be dying. A root canal was done;
this was a logical, if not necessarily correct, diagnosis
This treatment for a dying tooth wasn't unusual,
except that a few weeks after the treatment was complete,
she was back in the dentist's office complaining of pain in
another tooth. The dentist repeated the same diagnostic sequence,
and the patient had another root canal. This continued to
happen until she'd had five of these procedures. Unfortunately,
the pain still travelled from tooth to tooth.
Sometimes the pain will migrate around the
mouth more quickly, and the patient tells the dentist that
pain in one tooth went away in a few days, but came back someplace
else—often, but not always, in the tooth directly above.
Patients have been referred for psychological counselling
because of migrating tooth pain. Since nothing appears to
be physiologically wrong with each painful tooth, the cause
seems to be psychological.
Most often migrating tooth pain is actually
a result of the tooth-gearing problem. A cycle of hitting
or banging the tooth is taking place. When a tooth is hit
or banged over a period of time, the nerve in the tooth becomes
inflamed. To protect that tooth, the jaw changes position
to prevent the contact that caused the tooth to become inflamed
and painful. Unfortunately, another tooth may then take the
brunt of the hitting or banging, and it, like the first tooth,
may become sensitive. The pattern can repeat itself indefinitely
until many teeth have gone through a mysterious pain cycle.
In many cases, this results in a mouth full of root canals.
With older people, because the dental care available in their
youth was less sophisticated than that available today, the
painful teeth may have been removed instead.
"Hitting" or "banging"
a tooth is a subtle process. No one consciously bangs a tooth.
But in a patient who is grinding or clenching, the tooth may
be taking the brunt of unnatural pressure, so the body unconsciously
changes the clenching pattern.
The issue of tooth pain is further complicated
because pain in a tooth can actually be "referred pain"
from anywhere in the face or other areas of the body. Nerves
send information along certain pathways. We don't know all
the reasons for referred pain, but we know some directions
pain might travel. For example, spasms in the Lateral pterygoid
muscles cause pain behind the eye. Similarly, pain in a tooth
may be referred from some other place.
Problems having nothing to do with TMJ or dental
status can cause referred tooth pain. Sinus problems, for
example, may cause pain in the upper back teeth. The roots
of the molars and the bicuspids sometimes intrude into the
sinus cavities, separated by only a thin layer of bone and/or
sinus membranes. Allergies may also cause tooth pain, often
because environmental and food allergies cause inflammation
in the sinuses.
Because we now know that mysterious or undiagnosed
tooth pain can be caused by TMJ, this condition should be
added to the list of possible causes for tooth pain. But because
TMJ patients have the same dental problems as everyone else,
problems such as decay, injury to the tooth, and abscess should
be investigated thoroughly, too.
Facial pain is another symptom that can be
quite mysterious and difficult to diagnose. Pain in the face
is sometimes experienced along with a headache. People frequently
say, "My head hurts so much that my face is in pain,
too." Many people consider a pain in the head normal,
but pain in the face spells alarm. Actually facial pain can
be referred pain from a tooth problem, a sinus problem, or
from an injury to the head.
There is also a condition called tic douloureux,
which is a facial pain syndrome. It is characterized by intense
short-lasting pain, and has a trigger point in the face. A
person with this problem may not have any pain until this
trigger point is touched. Patients with tic douloureux will
actually shave or apply makeup around that trigger point.
This is quite different from the facial pain associated with
TMJ. Facial pain that is caused by TMJ problems usually lasts
longer and does not have a particular point that triggers
the pain. TMJ and tic douloureux can exist together. In these
patients it seems that, as with migraines, TMJ triggers the
problem to be more frequent and severe.
An occasional patient suffers only facial pain
or perhaps one or two other TMJ symptoms. A few have facial
pain with the cycle of bruxing and tooth pain, leading to
a confirmation of a dying- tooth diagnosis. It isn't unusual
for a patient to have facial pain when a tooth is abscessed.
PAIN AND NOISE IN THE JAW AND JOINT
Pain along the jaw should be distinguished
from pain felt in the joint itself. Jaw pain is common when
people have dental problems, and it sometimes accompanies
bruxing. But it is also a symptom of a heart attack, and a
person experiencing sudden jaw pain should not assume it is
a dental concern or TMJ.
Pain felt in the joint itself can also have
numerous causes. Sometimes the pain is accompanied by a popping
or a clicking in the joint. This popping or clicking sound
is rarely associated with pain. The source of the noise is
the cartilage disc that protects the bones of the joint by
preventing the bones from touching each other. When functioning
normally, the disc is intact and moves smoothly and in a coordinated
fashion with the jaw as it goes through its range of motion.
But if the cartilage disc becomes uncoordinated
for any reason, it will slip out of position, producing a
popping sound, and then making another popping sound as it
moves back in. The disc can be out of its normally smooth
co-ordination for many reasons—loose ligaments, lack
of co-ordination in the muscles, a tear in the disc, or displacement.
Some patients never experience this symptom—it
is common but by no means universal. Some people report this
popping only when they open their mouths very wide, as in
yawning or taking a bite of a large sandwich. The jaw also
may lock at these times. The popping or clicking sound can
be loud and bothersome. It should always be evaluated, because
it can indicate damage to the joint or the cartilage disc.
These popping or clicking sounds are different
from the sounds produced in other joint- derangement conditions
such as arthritis. Joint derangement from arthritis makes
a crackling, gritty sound, somewhat like sand in a gear. Often
the patient can hear it, and the examining clinician can hear
it with a stethoscope. In some cases, the sounds are loud
enough to be heard by someone standing close to the patient.
This crackling or gritty sound indicates damage
to the joint. This kind of damage can cause pain, and in keeping
with the idea of referred pain, it's possible that damage
to the joint may cause other symptoms such as headache.
However, in most TMJ patients, symptoms that
seem to be related to the joint itself are not caused by the
joint. They are actually caused by the muscle spasms most
often seen in patients with joint popping or pain. The joint
can't cause the muscle to go into spasm directly, and the
ultimate cause is the tooth-gearing problem.
As will be discussed in Chapter 11, surgery
is often considered the solution for people whose symptoms
are directly connected to the joint itself. However, when
muscle spasms are present, it is advisable to put off such
drastic treatment until there is an attempt to relieve the
pain with the standard treatment approach as it is most often
Each of the symptoms described can occur alone
or together with the more common symptoms—headaches,
neck and shoulder pain and stiffness, etc. There are people
with all of them and people seeking help with only one that
manifests in a severe and debilitating way. Some symptoms
appear to be related to the teeth and the jaw mechanism itself,
but there are two other symptoms to be discussed which seem,
on the surface, to have nothing whatever to do with a gearing
problem in the teeth.