TMJ is a frequently used term. Almost everyone knows someone who “has TMJ.” Well, the term TMJ is simply an abbreviation for temporomandibular (or TM) joint. This joint is the hinge by which the jaw is connected to the side of the head, in front of the ear, so in a sense we all “have” TMJ. By contrast, those who have a problem with this joint, an unrecognized multitude, may experience anything from a mild nuisance to a seriously disabling condition.
The jaw hinges on two ball-like swivels (condyles), each the size of a fingertip. Each swivel, bathed in sticky fluid, turns and slides on a small cushion of cartilage. The whole mechanism is smooth, silent and painless. Opening and closing the mouth, whether to talk, sing or chew, involves several sets of muscles. Some of these muscles (especially those that close the mouth) are very powerful: just consider the circus performer who dangles from a trapeze, holding on with teeth only. The TM joints bear much of the weight of such activity. You can feel the joint at work by placing your open hands, palms forward at the level of your ears. Now insert your little finger tip (facing forward) into the ear canal, then open and close your mouth. The ball at the top of the jaw moves forward and backward into the ear canal. This should be smooth and pain free.
Although TMJ problems are common, they are often misdiagnosed. This is because the symptoms of TMJ disfunction may be vague, and often misleading. Certainly if someone hears crackling in the ear on opening the mouth, the diagnosis is self-evident. But how about someone who complains of chronic earache, ringing in the ears, or even dizziness? Or someone who wakes up in the morning unable properly to open the mouth?
The cause of most TMJ problems begins with the muscles of the jaw. These muscles, involved in chewing or closing the mouth, can also be felt, by placing your fingers below the ears or over your temples, then clenching your teeth. Some patients carry a great deal of tension in these jaw muscles. For singers this is a particular problem. Not only are you limited in opening the mouth properly, but the tension is carried over to adjacent muscles in the neck and larynx. The result is increased tension in the throat, a high laryngeal position and excessive tension on phonation. An inadequately relaxed pharynx also has adverse effects on the resonating cavities above the larynx.
How to deal with TMJ problems? The first step, of course, is to identify the problem. I often see patients with TMJ-related earache who have been given antibiotics for a nonexistent ear infection. Once the condition has been identified, the cause should be eliminated. In acute situations, this is relatively easy. Acute TMJ problems may result simply from sitting at the dentist for two hours with your mouth propped open. Or from a misalignment of the bite due to a filling that has been left too high. Or from tearing through a particularly chewy bagel.
Chronic types of behavior, while also identifiable, are more difficult to change. A gum chewer may be told to stop, but the need for oral gratification will persist, and chewing candies is not a solution. Many people grit and clench their teeth when angry or under stress. Even more common is unconscious nighttime clenching and grinding. Some of these patients wake up with earache and jaw spasm, and can at times be identified by the patterns of wear on the teeth.
Treatment of an acute or infrequent TMJ irritation may be as simple as a short prescription of soft foods and anti-inflammatory medication. Getting someone to stop chewing gum (or, historically, to stop clenching a pipe between the teeth) is more difficult. Stress-related clenching may even require therapy.
A tooth guard worn at night can reduce grinding and save both the teeth and the TM joints, although not everyone can tolerate sleeping with an appliance in their mouth. The cause of nighttime grinding may sometimes be successfully addressed; an allergy causing irritation of the pharynx or nasal obstruction can trigger this behavior.
It is the rare TMJ patient who requires cortisone injections or surgery. Some cases, particularly those where the joint irreparably damaged by trauma or generalized arthritis, fall into this category. Before you undergo such surgery, be sure to get a second opinion: operated jaw joints rarely, if ever, become “normal” again.
A unique and new approach to muscle tension and TMJ dysfunction may be around the corner. Dr. Andrew Blitzer of New York, a pioneer in Botox treatments, is conducting a clinical trial looking at temporarily relaxing the jaw muscles with this medication. It is hoped that by reducing the tension on the joint for several months, the condition will resolve.
In most cases, however, simple measures will suffice. While in some cases the problem can be ignored, it should never be overlooked. Among singers in particular, even minor TMJ problems should be identified, since they can affect the singing mechanism.
DISCLAIMER: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific medical advice, or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.
