EBHSG - MARCH 1997 MEETING NOTES
TOPIC: "OH, MY ACHING JAW!"
Steven Goldman, D.D.S., spoke at the March 11, 1997 meeting of the East Bay Headache Support Group. The meeting was held in the Ball Auditorium at John Muir Medical Center from 7:30 to 9:00 PM, and 17 people were in attendance.
Dr. Goldman’s topic was Temporomandibular Joint Disorders and how they relate to headaches and facial pain, and dental occlusion (bite). He also tried to clear up some of the misconceptions we might have about this condition. TMD Syndrome is an entity with a lot of different names. It is now referred to as TMD, but many still know it as TMJ. A syndrome means a collection of clinical symptoms. TMJ stands for the jaw joint – many times pain in the jaw joint is mistaken for an earache. Many different symptoms may signify a problem with the jaw joint: it may click, pop, be off to the side, be painful.
Since 1935 or so, it was believed that pain in your jaw was all due to your bite. Doctors thought that all they had to do was to fix the bite. But people of different races exhibited different variations in bites, such as Africans with upper and lower jaw protruding. Many people had jaw problems, and their bites were okay. Doctors now know that fixing your bite is not a guaranteed cure of TMD.
Most jaw problems (pain) fall into two categories:
There is neurogical pain and dull, aching pain.
The jaw has unique features:
* Mostly it can be disarticulated (the joint is not a ball and socket—it is hanging loose and connected by muscle and ligaments).
* There is a little disk inside the jaw joint (a cushion without nerve endings), so the joint can function as a hinged joint, and it also slides two ways, like pliers. The joint can take lots of pressure because there are no nerve endings.
Some jaw conditions:
* Some people have a displaced disk in their jaw joint—This was discovered about ten years ago and became a popular theory for jaw problems. About 20% of patients who see their doctors for jaw problems have this condition.
* You may have a click in your jaw—leave it alone if you don’t experience any pain. Jaw noise may not get worse--don’t worry about it.
* Articulation of the joint. The jaw joint can break down.
People can develop arthritis in their jaw, but usually it strikes other places first. Traumatic arthritis can appear, which may have been caused by a blow to the jaw, or clenching one’s teeth, etc.
Not usually unilateral, but systemic…
Usually, broken down joints don’t cause pain. Pain is usually on the opposite side of the joint that looks bad. Usually problems are associated with the musculature. The temporalis muscle is the main cheekbone muscle which forms a sling for the jaw. Any pain in your life brings stress. We internalize stress and then walk around with our teeth locked together (clenched teeth). Much of jaw facial pain is caused by muscle contraction. Some is a conscious muscle contraction during the day (which is a habit), and other muscle contraction takes place while we sleep (grinding teeth, etc.). Grinding teeth tends to occur during a shallow sleep level. Medication can be taken to drop sleep levels to keep one from grinding his/her teeth during the night, and also to allow the patient to get more rest so that he can tolerate pain better while awake.
How much cross-over is there? Dr. Goldman said that so many times pain is not caused by one thing—it can be many different triggers. It is very important that you get your medications from one doctor.
Dr. Goldman has been involved at UCSF many years--25 years ago everyone who came to the TMJ clinic received a piece of plastic in their mouths (a splint to correct their bite).
There are many types of head pain—most muscular pain is low grade, chronic, continuous, achy, may never leave.
He mentioned lots of safe things one can do if suffering from jaw problems:
Chronic pain becomes more complicated—if it lasts for more than three months, we start getting depressed. Then a cycle starts where we don’t get good sleep.
If suffering from long term chronic pain, ask your physician for a psychological exam.
TMD is not just a "bite" problem. It can be caused by bad habits and stress. There is not a "cure." Learn to manage the condition, and educate yourself. Try seeing a biofeedback therapist, or a physical therapist. Often one can get great results from therapists. It is best to have a combination of professionals working together to get results.
A question was asked by a member of the audience: "Are doctors coming up with new explanations for TMD?" Dr. Goldman answered, "No, no new conditions have shown up. Now we’re being more honest about what we’re seeing."
Dr. Goldman stressed a conservative approach to correcting jaw problems. He said that fifteen years ago surgery was a common remedy, whereas now only 2% of patients must undergo surgery. Dr. Goldman’s patients are referred by doctors, dentists, attorneys, and other patients.
A splint, or plastic retainer, covers your teeth to give you an artificial bite. It is a soft material and it gets mixed-bag results: For some, it works fine. For others, it acts as a stimulus, and increases the activity of the jaw while asleep. Splints do work. Be careful, though. It is not good to wear a splint 24 hours a day unless closely supervised. Bites will change after wearing a splint—enough that you might need to move bones surgically to correct it. A splint is not dangerous if used at night only, though.
Have your splint checked at least once a year. Your regular dentist can check it to see if it is fitting properly, or if any teeth are uncovered.
Dr. Goldman mentioned that we shouldn’t mix muscular-type headache with migraine. Then Dr. Stein said that a tension-type headache can develop into a migraine. Tension headache may or may not respond to Imitrex.Dr. Goldman said we should try behavior modification first, before using drugs to relieve a jaw problem.
If you have a muscular headache which might be related to a jaw problem, try the following:
The drug family has two distinctive actions: Anti-depressant effect and analgesic effect.
We need to get past our ideas that we are not depressed so we can’t take these drugs. The use of narcotics is not an integral part of treatment for a jaw problem.
There are two classes of anti-depressants:
* SSI’s, such as Prozac, Zoloft, Paxil (we don’t know if they have an analgesic effect also)
* Tricyclics: A, B neurotransmitters (two kinds)
Two drugs were discussed: Elavil uses serotonin, can cause weight gain. There is less problem with weight gain when using Pamelor.
Ellen Place, a biofeedback therapist, asked: "Are hormones related to jaw pain"?
Dr. Goldman answered: "There are female hormone receptors in the jaw joints. It is known that TMD is more prevalent in women than men."
Ellen said that she sees more headaches and TMJ problems in women who are going through perimenopause, menopause, or are using hormone replacement therapy.
Neurotransmitters act as stimulators.
Dr. Goldman mentioned that almost all medications used to prevent headaches cause weight gain (and sometimes hair loss).
Ellen Place suggested that hormone replacement therapy (HRT) should be adjusted when a woman is also taking neurotransmitter drugs.
Dr. Stein asked, "When teenagers get braces, does that cause an increase in headaches?"
Dr. Goldman said that young people don’t seem to have headaches which might be caused by braces, but he has seen it in adults with braces. If you have had prior jaw problems, it probably would be advisable for you not to get braces on your teeth.
How often are bites adjusted by a dentist filing down a patient’s teeth? Dr. Goldman said filing down teeth won’t cure a facial pain problem.
TMD and ear pain—the most common complaint is that it feels like ear pain. Have your ears checked to rule them out.
Dick Tomchalk asked: "Does gum chewing cause TMD problems?" and Dr. Goldman’s answer was, "Yes." He tells his 15- to 17-year old teenage patients to get rid of the gum and their jaw problem usually goes away.
"Unloading" the jaw joint—clenching teeth at night causes ear pain headaches for one participant who doesn’t use her splint every night. Dr. Goldman explained that it is okay to use your splint occasionally, but if you notice that you wake up in the morning with ear or facial pain, try using it again and see if that helps.
A member of the audience asked if there is a benefit to chiropractic realignment. She finds temporary relief from it. Dr. Goldman responded that a jaw is only out of place when it is wide open. He questioned what the chiropractor means by "out of place."
Dr. Goldman passed out a booklet called "Orofacial Pain, Temporomandibular Disorders," which is attached.
The intention of the East Bay Headache Support Group is to provide information and resources. It does not provide medical advice, which should be obtained directly from a physician.
The notes provided above were taken by an EBHSG volunteer and have not been reviewed by the speaker for accuracy. If you have any questions regarding the notes, please contact the EBHSG.