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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.

FULL 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 for help.

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 was advantageous.

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 TMJ problems.

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 TMJ.

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 is unadvisable.

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 as well.

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 diagnosis.

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 tumor.

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 had been.

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 people.