Definition

A collective term to describe a number of problems of the muscles of the jaw, the temporomandibular joint, and associated structures.


Symptoms

Jaw pain • Locking • Clicking • Grinding • Earache • Ringing in the ears (tinnitus) • Neck pain • Headache • Difficulty biting and chewing


Etiologic Considerations — Primary

  • Dental—malocclusion, wisdom teeth, brux-ism
  • Psychological—stress, anxiety, depression
  • Physical—scoliosis, congenital and develop-mental disorders
  • Drugs—caffeine, cocaine, amphetamines
  • Arthritide—osteoarthritis, rheumatoid arth-ritis
  • Trauma—previous jaw fractures
  • Habitual factors—gum chewing, biting nails, holding phone between the ear and shoulder
  • Congenital variations/ abnormalities

Etiologic Considerations — Secondary

  • Cardiac—myocardial infarction (heart at-tack), angina refers pain to the jaw
  • Gastrointestinal—gastric reflux refers pain to the jaw

Discussion

Temporomandibular joint disorder (TMJ) is a notoriously complicated problem, and one that has plagued humanity since pre–Egyptian times.1 The jaw is one the most actively used joints in the body and plays a pivotal role in our well-being by allowing proper mastication and communication. The joint links the mandibular bone to the temporal bone of the skull. Between the two bones is a strong fibrocartilaginous disc.

In normal joint function, the mandible should rotate first, like a screwdriver, and then translate forward on the disc. Problems can arise in various ways; the most common is a dental malocclusion. If the top and bottom teeth are not aligned, this leads to repetitive torsion or increased loading on either side. Eventually this progresses to misplacement of the disc, clicking, pain, and eventually arthritis. In TMJ, there will be a change to normal motion, one or both sides of the jaw will translate early and the synchronous jaw opening will be lost. This can been seen when patients open the mouth, the chin will deviate to one side. The exercises at the end of this chapter have been designed to correct this. Like any joint, the muscle tension around the joint plays a pivotal role in its function. If the muscles are

contracted for long periods such as with grinding or clenching of the jaw, they will develop painful trigger points. Studies have shown that during stressful periods the muscle tension increases, whereas during a restful period the muscle is much more relaxed.2 Coffee intake has also been shown to increase the muscle tension around the jaw; this is indicative to how any stimulant or stress will aggravate the problem.3

The posture of the neck and back are intimately linked to the jaw; the classic example is a head thrust forward posture, which can lead to a forward displacement of the jaw. However, even distant musculoskeletal problems can contribute. It is not uncommon to find a one-sided knee or hip problem that alters the gait, changing the neck posture and leading to the jaw problem. Spinal dysfunctions in the neck need to be addressed during treatment.


Treatment

TMJ can be one of the most frustrating problems for patients to resolve. Pain in the jaw can affect all aspects of life, from exercise to sleeping and eating. When seeking help, however, people find that there is not a singular profession that focuses on this condition or is effective alone in resolving the pain. There are so many causes and factors to TMJ that the best approach is to have a small group of therapists to treat the problem, then include self-management, in the form of exercises and stress mitigation.

The first port of call should be your dentist. Dentists can help by treating dental malocclusion or fitting a splint. A properly fitted splint can help alleviate nocturnal grinding and can be designed to allow the jaw muscles to remain relaxed.

There are always secondary factors, such as stress, posture, and spinal dysfunction, that need to be addressed before the problem can be resolved. If malocclusion has been treated successfully or excluded, the next step is to seek a physical therapist. We are obviously biased toward osteopathy, as we are both trained in that field and because it provides a holistic and inclusive approach to treatment, but good results can be obtained if you have a fantastic physiotherapist, chiropractor, or massage therapist. The important factor is to have dysfunction of the muscles around the jaw, neck, and back treated. Significant relief can be obtained with inhibition (osteopathic techniques that arrest activity in a muscle by arousing activity in the nerve supplying it) and with massage and stretching of the muscles; spinal manipulation can relieve headaches associated with TMJ.4

Stress reduction can lead to significant reduction in TMJ pain. A stressful event will occur at work or home and unconsciously, the jaw will be clenched tight; often, people are not even aware that it is happening. This clenching can occur many times throughout the day and can progress to clenching and grinding at night. See Stress for stress-reduction techniques, and a consultation with a psychologist may help you recognize when and why this is happening and can teach you strategies to stop it.


Self-Management

Self-management plays a large part in resolving this problem. Once you realize that you can help the problem yourself, you can take ownership of your recovery.

In cases where malocclusion and serious pathology has been excluded, these exercises can alleviate jaw pain within a month.5

Instructions

  • Try to practice a relaxed lifestyle, set aside a little time once or twice a day to drain tension from the neck, head, and jaw. See Stress for an introduction to meditation.
  • It is important to be aware of sleeping posture; stomach sleeping will strain the neck and lead to misalignment of the jaw.
  • Try to avoid opening your mouth very wide, even opening wider that your thumb is too far.
  • Teeth should only touch lightly when you swallow, at all other times the teeth should never touch or be clenched.
  • Eat soft food and try not to bite food with your front teeth; food should be cut small and chewed evenly on both sides. Avoid chewing gum.
  • Self-massage your painful muscles, rubbing gently on the muscles around the angle of the chin and into the temporal area. You can hold gentle pressure on any painful area until it eases.
  • Apply heat or ice, or both.
    • Moist heat is usually most effective. Place a tea towel in warm water then wrap it around a hot water bottle. Place it on the side of the face for twenty minutes, two to four times a day. You can alternate sides.
    • Dry heat can also be effective and is less of a hassle.
    • Try icing the area, wrap a few ice cubes in a moist tea towel and apply to the area until you start to feel some numbness (about ten minutes).
    • Try a combination, heat for five minutes then ice.
  • Be mindful of your posture. If your head is jutting forward, try to sit tall and pull the chin toward your chest. If using a computer screen, check if the screen is too far away. Pulling the screen closer or increasing the font size can help stop the head from moving forward.

Self-Management Exercises

This is an exercise program based on the Southside Hospital approach. It can be effective at helping to normalize the position of the jaw and to regain healthy tracking and sequence of movement. The exercises are progressive, so begin with the first and once the exercise can be done comfortably and correctly, progress to the next.

Rotation and Translation Control 1
  1. Keep the tongue on the roof of the mouth.
  2. Place one finger on the most painful jaw and the other on the chin.
  3. Open and close the jaw with the guidance of the finger to ensure straight tracking (tongue stays to the roof of the mouth).
  4. Repeat five times, five times per day.
Rotation and Translation Control 2
  1. Keep the tongue to the roof of the mouth.
  2. Place both fingers on the jaw (TMJ) joints, just to the outside of the ear canals.
  3. Allow the jaw to open, watching in a mirror to ensure straight opening. (You do not want the chin to deviate to either side).
  4. Repeat five times, five times per day.
Rotation and Translation Control 3
  1. Start with your tongue on the roof of your mouth.
  2. Place one finger on the most painful jaw and the other on the chin.
  3. Open and close the jaw with the guidance of the finger to ensure straight tracking. This time, allow the tongue to drop and the mouth to open completely.
  4. Monitor yourself in a mirror, ensuring straight opening.
  5. Repeat five times, five times per day.
Rotation and Translation Control 4 (final)
  1. Keep the tongue to the roof of the mouth
  2. Place both fingers on the jaw (TMJ) joints, just to the outside of the ear canals.
  3. Allow the jaw to open, watching in a mirror to ensure straight opening. (You do not want the chin to deviate to either side).
  4. Then allow the tongue to drop and the jaw to open completely. Keep monitoring for straight opening in a mirror and with your fingers.
  5. Repeat five times, five times per day.

Stabilization Exercises Stage 1

These exercises help strengthen and stabilize, only very light pressure should be used and the jaw shouldn’t move during the activity.

  1. Maintain lower jaw position.
  2. Using the photographs A to F as a guide, use your finger to place gentle pressure in the directions shown.
  3. Hold for two seconds in each position. Remember that the chin should not move.
  4. Repeat five times, five times per day.

A. Pressure to the left

B. Pressure to the right

C. Pressure up to ceiling

D. Pressure toward neck

E. Pressure diagonally toward the left ear

F. Pressure diagonally toward the right ear

Progression 1

Repeat exactly as above except with the jaw one knuckles’ width apart (about ½ inch or 1 cm).

Progression 2

This should only be attempted when or if the jaw has completely-pain free movement.

Repeat as in stage 1, this time holding the jaw two knuckles’ width apart.

Additional Exercise

You need a piece of soft wood—ideally a carpenters’ pencil, a regular pencil, or just a small dowel from a hardware store.

Position the pencil at the back of the mouth, grasping it with the back molars with the chin thrusting forward.

Rhythmically bite the pencil, pulling the lower chin and teeth backward for two to three minutes at least three times a day.

  1. C. McNeill, “History and Evolution of TMJ Concepts,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 83 (1997): 51–60.
  2. J. D. Rugh and J. W. Robbins, “Oral Habits Disorder,” in Behavioral Aspects of Dentistry, edited by B. D. Ingersoll (Norwalk, CT: Appleton-Centry-Crafts, 1982).
  3. D. G. Simons, J. G. Travell, and L. S. Simons, Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed. (Baltimore, MD: Lippincott, Williams, and Wilkins, 1998).
  4. L. L. DeBar, N. Vuckovic, J. Schneider, and C. Ritenbaugh, “Use of Complementary and Alternative Medicine for Temporomandibular Disorders,” Journal of Orofacial Pain 17, no. 3 (2003): 224–36.
  5. J. Murtagh, General Practice, 3rd ed. (NewYork: McGraw-Hill, 2003).
Excerpts from Better Health Through Natural Healing 3rd Edition

First published in 1985, Better Health through Natural Healing has become one of the most successful and authoritative resources of its type, with more than 1.5 million copies sold worldwide. Since the original publication of this comprehensive guide, alternative therapies have become more and more accepted by the mainstream, and patients and practitioners of the wider medical community are embracing complementary medicine as an effective treatment option for a range of medical conditions.

The book is available at the West End clinic, exclusively in Australia.


More chapters from the book