Is that pain in your jaw or ear a sign of TMJ?

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. If you've got tenderness in your jaw or trouble chewing, and aching pain in and around your ear, you may have wondered if you have something called TMJ, temporomandibular joint dysfunction.

Physical therapists are among the health care providers who care for people with TMJ. And today I'm talking with Scott Hoskins. He's a doctor of physical therapy in Upstate's department of physical medicine and rehabilitation. Welcome to "The Informed Patient," Dr. Hoskins.

Scott Hoskins: Thank you.

Host Amber Smith: Can you please start by describing for us what TMJ is?

Scott Hoskins: Yeah. The TMJ, the temporomandibular joint, is a joint where the mandible, or the jawbone, attaches to the skull. So there's two; there's one on either side, and it's movement is important for eating, talking, facial expressions, really any movement of your face, and if they dysfunction, it's basically an umbrella term to describe any issue with those joints or the surrounding soft tissues.

Host Amber Smith: Does it involve just the jawbone itself or also the muscles around the jawbone?

Scott Hoskins: It's actually a very complex joint, so it's bones, where the bones connect, it's all the muscles around. There's multiple muscles that open and close your jaw, there's ligaments, there's connective tissue, joint capsule, and then there is a disc in between the bones that kind of acts as a cushion or a support for the joint.

Host Amber Smith: Well, is this condition something that people are born with, or does it develop as we age?

Scott Hoskins: In certain cases, there's congenital abnormalities of the bones, things like that, but most commonly, and most of the time when people think about TMJ dysfunction, it is something that develops at some point in life, and it's not necessarily with older age. The most common is females in the age range of, say, 20 to 40; somewhere in that range is the most common time to experience this.

Host Amber Smith: Do we have any idea of what causes it?

Scott Hoskins: It depends. It's usually multiple factors that go into it. A lot of times it's related to what we call oral parafunctions, so basically bad habits of your jaw. So it's like clenching your teeth, people who grind their teeth at night, excessive gum chewing or chewing caps of pens, things like that. A lot of times those bad habits can contribute. Posture is often a big contributing factor as well.

Host Amber Smith: So grinding teeth and other bad habits, like crunching on ice, chewing gum, all of that, can contribute to causing this, then.

Scott Hoskins: Yes. And nighttime habits as well, if you tend to clench your teeth while you're asleep or grind your teeth in your sleep, that puts you at a greater risk for developing these problems.

Host Amber Smith: So would those be considered risk factors?

Scott Hoskins: Yeah, I would say so.

Host Amber Smith: And you mentioned women between like 20 and 40. So I'm wondering, is there something hormonal that has to do with this?

Scott Hoskins: That is a theory, yes. It's kind of unclear at this point, but yeah, there's definitely theories that female hormones can play a role.

Host Amber Smith: Does this condition run in families? If you have parents that have had this, is a child more likely to get it?

Scott Hoskins: Possible, yes. In some cases it does seem that way. There is some research that shows that the predisposition to things like clenching and grinding your teeth can run in families, and there's also some theories that there is a genetic component to being predisposed to chronic pain conditions. So people who have those sorts of genes, yes, you would be more predisposed to TMJ issues.

Host Amber Smith: In terms of symptoms, pain in the jaw, trouble chewing, pain around the ear, what other symptoms are common?

Scott Hoskins: There's a variety. Those ones that you mentioned, yes, are all very common. One of the major ones is clicking and popping and noises in the joint. Headaches are very common as well, pain in the neck, and one that people might not necessarily think about is a ringing in the ears, changes in the ears, feelings of pressure, fullness, hearing changes, can all be related to TMJ dysfunction.

Host Amber Smith: Taking all of those symptoms together, it makes me wonder if there are other conditions that have to be ruled out before you can diagnose TMJ?

Scott Hoskins: Yeah, I think it's definitely important to do a good differential diagnosis and rule out any other possible causes of these symptoms. You would want to rule out any sorts of infection, obviously, like an infection in the tooth or an ear infection, or any sort of autoimmune disease process, like rheumatoid arthritis, things like that. And then you'd also want to carefully screen for neck problems. Some of these things that present with these symptoms can be coming from joint dysfunction or muscle problems in the neck, and then just sort of mimic these symptoms, so you would want to rule all those things out, for sure.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking with doctor of physical therapy Scott Hoskins about temporomandibular joint dysfunction. And we're getting into how TMJ is diagnosed.

Now I wonder, do people typically bring these complaints about these symptoms to their dentists? I mean, where would you advise people to go?

Scott Hoskins: That's one of the things that can be very frustrating for these patients, is there's no real clear consensus on where to go, like whether you go to your primary care doctor or you go to your dentist. A lot of times people aren't really sure. And that's something that we see a lot, is frustration. People have kind of been bounced around from provider to provider, but I think probably primary care is a good place to start: your family doctor, and then a referral to physical therapy is probably a good place to start.

Host Amber Smith: So can you walk us through how TMJ is diagnosed?

Scott Hoskins: Yeah. So to get to a diagnosis of TMJ, it's not really one specific test. It's usually we're looking more for a cluster of symptoms.

So it's usually some combination of a patient's subjective report, like when their pain occurs, things that aggravate their pain, the location of their pain, and usually presence of noises in the joint, like clicking and popping while you're chewing or talking, people will a lot of times hear noises.

And then there usually is a lot of tenderness around the area. So the muscles around the jaw and up into the side of the head tend to get really tender. So, that, and then looking at potentially changes in the range of motion of the jaw, so people can't open their mouth as far, and things like that. So it's usually we look for some combination of multiple symptoms, and that usually leads us to the diagnosis of TMJ dysfunction.

Host Amber Smith: Now let's talk about treatment options. What are patients typically told to do for TMJ? What do the primary care providers usually advise?

Scott Hoskins: That can be kind of a tough question also. It varies depending on the provider that they see. The most common thing is usually heat. A lot of times, people are advised to put hot packs on their jaw, on the side of their face.

And then usually some sort of pain medication, whether it's an anti-inflammatory or muscle relaxer, something like that. It depends on who they see. And then usually as a referral to maybe a TMJ specialist dentist or a referral to physical therapy.

Host Amber Smith: So what does physical therapy usually involve?

Scott Hoskins: It'll start with an assessment, so we'll have the person describe their symptoms, things that aggravate it, things that relieve it, location. And then we'll just get an overall picture of how they move, like their posture. We'll look at their neck usually first; a lot of times, there's a close relationship between how the neck functions and how the jaw functions. So we take a close look at the neck, the range of motion, how the joints move, how the muscles work, and then we'll look at the jaw itself, how the muscles feel in the jaw. Depending on what we find, we'll get into some treatment, which is usually some combination of manual therapy, which would be like massage or stretching, things like that. And then, exercises.

Host Amber Smith: Does TMJ affect a person's ability to eat and speak?

Scott Hoskins: Yes. A lot of times that is the biggest complaint that people have, is trouble eating. Especially larger food items or harder foods, like crunchy foods, tend to be quite painful.

So a lot of times we'll have people come in and they, for example, they can't eat a full apple. They have to cut it into small pieces, or like steak, things that take a lot of chewing. That is usually people's main complaint when they to see us.

Host Amber Smith: So how long does the typical physical therapy course last?

Scott Hoskins: It's variable. I would say probably, on average, it would be maybe one to two visits a week for six to eight weeks, somewhere in that range. And usually it may be 45 minutes per session, somewhere in that range.

Host Amber Smith: And hopefully a person would see some improvement during that time?

Scott Hoskins: Yeah. Depending on the root cause of the symptoms. Sometimes it can be very quick, sometimes it can take longer, but yeah, typically in that time frame, you would see quite a bit of improvement in your symptoms. And then our goal is to give patients the tools to manage these symptoms on their own.

So ideally by the end of your course of physical therapy, you know all the stretches and all the exercises, things you need to do to be able to manage your symptoms by yourself.

Host Amber Smith: How would someone find a physical therapist with specialization in TMJ? Because this is not something that every physical therapist offers. Is that right?

Scott Hoskins: Correct. Yes. And this is another thing that can be frustrating. A lot of times it is hard for patients to find somebody who does specialize in treating TMJ, and there's no real central database of where to find it. I would just recommend when you call a physical therapy clinic, just make sure you ask before you set up your appointment, make sure if there is somebody at that clinic who can treat the TMJ.

Host Amber Smith: Is surgery ever recommended?

Scott Hoskins: In more advanced cases, yes.

Host Amber Smith: How involved does that get?

Scott Hoskins: Again, that can vary, so it can start kind of anything as basic as something that is called an arthrocentesis, where it's basically a very small incision, and then they flush the joint space with a sterile fluid. And the idea with that is you flush out any of the inflammatory cells or break up any adhesions that are messing with the way the joint moves, so that's kind of the least invasive procedure. It can be up to something like repairing the disk that's in the joint space or repositioning that disk, or sometimes even removing that disk completely just to kind of free up the movement of the joint. And then it goes all the way up to a complete replacement of the joint.

Scott Hoskins: Just the way somebody would have their knee joint replaced, you have your TMJ replaced as well.

Host Amber Smith: Can TMJ be permanently fixed, or is this a condition that may flare up from time to time for the rest of the person's life?

Scott Hoskins: Again, that kind of depends on what is the root cause of it. I would say in general it can be permanently fixed if you address the root cause. So whether it's correcting the posture, whether it's behavior modification, like changing, like we mentioned before, those bad habits that kind of lead to it. If you can permanently change those, it should permanently affect the symptoms. And then maintaining your home exercise program. Usually there is some part of your exercises that you will have to keep up with forever, just to maintain things. So, if patients are good about taking care of themselves, taking care of their symptoms, it's usually something they can manage. And then again, our goal is to provide the tools to the patients.

So if somebody does have a flare-up, they know what to do, they know what stretches they need to do, or increase frequency of, they know what exercises they need to do. They know what kind of things they have to change and avoid to take care of their symptoms by themselves.

Host Amber Smith: Well, before we wrap up, what are the things people can do to prevent the development of TMJ or at least to try to prevent the development of TMJ?

Scott Hoskins: Yeah, there's definitely things you can do.; So the easiest things are: Minimize excessive chewing. So if you're somebody who is constantly chewing gum throughout the day, chewing on pens and pencils, things like that, trying and minimize that, if you can.

Being aware of your posture -- if you're always in a slouched or forward-head position, that affects the mechanics of the jaw. So being more aware of your posture, sitting up straight, keeping your shoulders back.

Stress management is a big thing. If you're somebody who's always tense and holding your shoulders up, that's going to affect all the muscles in the front of your neck and your jaw. And everything's just going to be sort of tight. So stress management is a huge thing.

As much as you can, nighttime behavior modification. So if you're somebody who clenches her teeth or grinds her teeth while you sleep, possibly a mouth guard, which your dentist will be able to provide, can be helpful and minimize that extra stress on the jaw throughout the night.

It can be kind of a hard fix, but if you can make this your habit, it can be very beneficial. There is something that we call the resting position of the jaw. when you're not using your mouth for eating or talking or whatever, you want your habit to be, to keep your lips together, keep your teeth slightly apart and then have your tongue just gently relaxed on the roof of your mouth.

Scott Hoskins: So that is the position where there's the least stress on it -- the joint -- so the more you can make that your habit, the less stress there is on the TMJ.

Host Amber Smith: That's good to know. I appreciate you making time for this interview, Dr. Hoskins.

Scott Hoskins: Yeah, no problem. Thank you.

Host Amber Smith: My guest has been doctor of physical therapy Scott Hoskins from Upstate's department of physical medicine and rehabilitation. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.