What causes TMJ-related ear pain. How can you differentiate TMJ ear pain from other types of ear discomfort. What are effective treatments for TMJ-induced ear pain. How can lifestyle changes help alleviate TMJ symptoms and associated ear issues.

The Temporomandibular Joint: Anatomy and Function

The temporomandibular joint (TMJ) is a complex hinge that connects the jaw to the skull. Located just below the ears on either side of the head, this joint plays a crucial role in various daily activities. But what exactly is the TMJ, and how does it work?

The TMJ is a synovial joint that allows for both sliding and hinging movements. It consists of the mandibular condyle (the rounded end of the lower jaw) and the mandibular fossa (a depression in the temporal bone of the skull). A small disc of cartilage sits between these two bones, acting as a cushion and facilitating smooth movement.

This joint is essential for several functions:

• Chewing and grinding food
• Speaking and vocalizing
• Yawning
• Swallowing

Given its frequent use and complex structure, it’s not surprising that the TMJ can sometimes become a source of discomfort and pain, including referred pain in the ears.

TMJ Syndrome: Causes and Symptoms

TMJ syndrome, also known as temporomandibular joint disorder (TMD), is a condition that affects the jaw joint and surrounding muscles. But what causes this condition, and how can you recognize its symptoms?

Common Causes of TMJ Syndrome

• Bruxism (teeth grinding or clenching)
• Jaw misalignment
• Arthritis in the joint
• Trauma or injury to the jaw
• Stress and tension
• Poor posture

Recognizing TMJ Syndrome Symptoms

TMJ syndrome can manifest in various ways, often affecting areas beyond just the jaw. Common symptoms include:

• Pain or tenderness in the jaw
• Difficulty or pain when chewing
• Clicking or popping sounds when opening or closing the mouth
• Facial pain
• Headaches
• Earaches or ear pain
• Tinnitus (ringing in the ears)
• Dizziness
• Neck and shoulder pain

Is TMJ syndrome more prevalent in certain populations? Research suggests that women are significantly more likely to experience TMJ pain than men, with some studies indicating they are up to nine times more susceptible.

The Connection Between TMJ and Ear Pain

One of the most perplexing aspects of TMJ syndrome is its ability to cause ear pain. How exactly does a jaw problem lead to discomfort in the ears?

The connection between TMJ and ear pain can be attributed to several factors:

1. Proximity: The TMJ is located very close to the ear canal and middle ear structures.
2. Shared nerve pathways: The trigeminal nerve, which serves the jaw area, and the facial nerve, which affects the ears, are closely interconnected.
3. Referred pain: Pain from the jaw muscles can be “referred” or felt in nearby structures, including the ears.
4. Eustachian tube dysfunction: TMJ issues can sometimes affect the function of the Eustachian tubes, leading to ear discomfort.

Can TMJ-related ear pain be mistaken for other ear conditions? Indeed, it can. This is why it’s crucial to consult with a healthcare professional for an accurate diagnosis. TMJ-related ear pain may be accompanied by other TMJ symptoms, whereas isolated ear pain might indicate a different underlying condition.

Diagnosing TMJ-Related Ear Pain

Accurately diagnosing TMJ-related ear pain is crucial for effective treatment. How do healthcare professionals differentiate between TMJ-induced ear pain and other ear conditions?

Diagnostic Procedures

• Physical examination of the jaw and surrounding muscles
• Assessment of jaw movement and listening for clicking or popping sounds
• Palpation of the TMJ and associated muscles to check for tenderness
• Evaluation of bite alignment
• Imaging tests such as X-rays, CT scans, or MRI to visualize the joint structure

During the diagnostic process, your healthcare provider may ask about your medical history, including any recent injuries, stress levels, and habits like teeth grinding. They may also inquire about the nature and duration of your symptoms.

Is it possible to have TMJ-related ear pain without other obvious TMJ symptoms? Yes, in some cases, ear pain may be the primary or only noticeable symptom of TMJ disorder. This is why a comprehensive evaluation is essential for an accurate diagnosis.

Conservative Treatments for TMJ-Related Ear Pain

Once TMJ-related ear pain is diagnosed, what are the initial treatment options? Fortunately, many cases of TMJ disorder can be managed with conservative, non-invasive approaches.

Self-Care Measures

Several self-care strategies can help alleviate TMJ-related ear pain:

• Applying warm or cold compresses to the jaw area
• Practicing relaxation techniques to reduce stress and tension
• Avoiding hard or chewy foods
• Refraining from wide yawning or excessive talking
• Maintaining good posture

Medications

Over-the-counter pain relievers and anti-inflammatory medications can often provide relief:

• Ibuprofen
• Naproxen
• Acetaminophen

In some cases, your healthcare provider may prescribe stronger pain relievers or muscle relaxants for short-term use.

Physical Therapy and Exercises

Specific exercises and stretches can help improve jaw function and reduce pain. These may include:

• Gentle jaw stretches
• Chin tucks
• Resistance exercises
• Relaxation exercises for the jaw muscles

How long does it typically take to see improvement with conservative treatments? While individual responses vary, many people experience some relief within a few weeks of consistent treatment. However, it’s important to be patient and persistent, as full recovery may take several months.

Advanced Treatment Options for Persistent TMJ-Related Ear Pain

When conservative treatments fail to provide adequate relief, what other options are available for managing TMJ-related ear pain?

Oral Appliances

Custom-fitted oral appliances, often called splints or night guards, can be highly effective in managing TMJ symptoms. These devices work by:

• Reducing pressure on the jaw joint
• Preventing teeth grinding and clenching
• Promoting proper jaw alignment

Oral appliances are typically worn at night but may sometimes be recommended for daytime use as well.

Botox Injections

Botulinum toxin (Botox) injections can help relax the jaw muscles, potentially reducing pain and improving function. This treatment is particularly useful for individuals whose TMJ symptoms are primarily caused by muscle tension or overactivity.

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS therapy uses low-level electrical currents to stimulate nerves and muscles, potentially providing pain relief and improving jaw function.

Surgical Interventions

In rare cases where conservative treatments and minimally invasive options fail to provide relief, surgical intervention may be considered. Surgical options can include:

• Arthrocentesis (joint fluid removal and lubrication)
• Arthroscopy
• Open joint surgery

Is surgery common for TMJ disorders? No, surgical interventions are generally considered a last resort and are only recommended in severe cases that have not responded to other treatments.

Lifestyle Modifications to Manage TMJ-Related Ear Pain

Beyond medical treatments, what lifestyle changes can help alleviate TMJ symptoms and associated ear pain?

Dietary Adjustments

Modifying your diet can significantly reduce stress on the TMJ:

• Choose softer foods that require less chewing
• Cut food into smaller pieces
• Avoid chewy or sticky foods
• Limit consumption of hard foods like nuts and hard candies

Stress Management

Since stress can exacerbate TMJ symptoms, implementing stress-reduction techniques can be beneficial:

• Practice mindfulness meditation
• Engage in regular exercise
• Ensure adequate sleep
• Consider cognitive-behavioral therapy

Posture Improvement

Poor posture can contribute to TMJ issues. Tips for better posture include:

• Be mindful of your sitting and standing posture
• Use ergonomic furniture and equipment
• Take regular breaks to stretch and move
• Consider posture-focused exercises like yoga or Pilates

Habit Modification

Certain habits can worsen TMJ symptoms. Try to avoid:

• Chewing gum
• Biting nails or other objects
• Clenching or grinding teeth (often done unconsciously)
• Resting your chin on your hand

How long should you maintain these lifestyle changes? For optimal results, these modifications should be considered long-term habits rather than temporary fixes. Consistency is key in managing TMJ symptoms effectively.

The Role of Alternative Therapies in Managing TMJ-Related Ear Pain

While conventional treatments are the mainstay of TMJ management, some individuals find relief through alternative or complementary therapies. What are some of these options, and how might they help?

Acupuncture

This ancient Chinese practice involves inserting thin needles into specific points on the body. Some studies suggest that acupuncture may help reduce TMJ pain and improve jaw function by:

• Promoting relaxation of jaw muscles
• Stimulating the release of natural pain-relieving chemicals in the body
• Improving blood circulation in the affected area

Massage Therapy

Professional massage, particularly focused on the jaw, neck, and shoulder areas, can help alleviate TMJ symptoms by:

• Reducing muscle tension
• Improving blood flow
• Promoting relaxation

Chiropractic Care

Some individuals find relief through chiropractic adjustments, which may help by:

• Improving jaw alignment
• Addressing related neck and spine issues
• Reducing overall musculoskeletal tension

Herbal Remedies and Supplements

Certain herbs and supplements are thought to have anti-inflammatory or pain-relieving properties that may benefit TMJ sufferers:

• Turmeric
• Omega-3 fatty acids
• Glucosamine and chondroitin
• Bromelain

Are these alternative therapies scientifically proven to treat TMJ-related ear pain? While some individuals report benefits from these approaches, scientific evidence for their efficacy in treating TMJ disorders is often limited or mixed. It’s crucial to consult with a healthcare professional before starting any alternative treatments, especially if you’re taking other medications.

Preventing TMJ-Related Ear Pain: Proactive Measures

While not all cases of TMJ disorder can be prevented, there are steps you can take to reduce your risk or minimize the severity of symptoms. What proactive measures can help prevent TMJ-related ear pain?

Maintain Good Oral Hygiene

Proper dental care can help prevent issues that may contribute to TMJ problems:

• Brush and floss regularly
• Address any dental issues promptly
• Attend regular dental check-ups

Practice Proper Jaw Posture

Being mindful of your jaw position throughout the day can help reduce strain:

• Keep your teeth slightly apart when not eating
• Avoid clenching or grinding your teeth
• Be aware of jaw tension during stressful situations

Use Proper Chewing Techniques

How you chew can impact your TMJ health:

• Chew food evenly on both sides of your mouth
• Avoid chewing on only one side
• Take smaller bites to reduce jaw strain

Manage Stress Effectively

Since stress can exacerbate TMJ issues, developing good stress management habits is crucial:

• Practice relaxation techniques regularly
• Engage in stress-reducing activities like exercise or hobbies
• Seek professional help if stress becomes overwhelming

Maintain Overall Health

General health practices can contribute to TMJ health:

• Stay hydrated
• Eat a balanced diet rich in anti-inflammatory foods
• Get regular exercise
• Ensure adequate sleep

Can these preventive measures guarantee you won’t develop TMJ-related ear pain? While these strategies can significantly reduce your risk, they cannot provide absolute prevention. Some factors contributing to TMJ disorders, such as certain genetic predispositions or structural abnormalities, may be beyond individual control. However, adopting these habits can help maintain overall jaw health and potentially minimize the severity of symptoms if TMJ issues do develop.

What to Do for TMJ-Related Ear Pain?

Posted on December 21, 2019

Category: TMJ-related ear pain

The temporomandibular joint, or “TMJ,” is the hinge that connects the jaw to the skull, located just below the ears. You use this joint every time you chew, swallow, yawn, and talk.

Issues occurring with the TMJ produce a variety of symptoms, one of which is ear pain ranging in intensity from mild to severe.

If you suffer from TMJ-related ear pain, there are several ways you can get relief. Read on as Dr. Ivan Stein of the Headache & TMJ Center of New Jersey shares five tips to improve the tension triggering your ear pain.

Perform Specific Exercises and Stretches

Performing certain exercises can relax and strengthen the jaw and its connecting muscles and improve joint movement. Over time, this can provide ear-pain relief.

Examples of exercises you can perform include chin tucks, opening and closing the mouth, side-to-side and forward jaw movements, and various relaxation techniques.

Exercises shouldn’t be done if you’re experiencing extreme discomfort, though. Start any exercise slowly, as you may feel some resistance but the sensation should be tolerable and gradually get better.

Modify Your Diet

If you eat a lot of hard, chewy or crunchy foods, your diet may be contributing to your TMJ-related ear pain. Choose softer, less-chewy foods instead, as they are less likely to strain the jaw. You should also avoid chewing gum.

Make Lifestyle Changes

In addition to dietary modifications, making other simple lifestyle changes can alleviate TMJ-related ear pain. Here are a few easy suggestions:

• Avoid biting the lower lip and fingernails
• Maintain good posture
• Keep the upper and lower teeth separated to prevent the jaw from clenching
• Limit activities involving big jaw movements, such as yawning and singing

Wear a Mouth Guard

Since TMJ-related ear pain may result from nighttime teeth grinding or jaw clenching, wearing a mouth guard may help. A mouth guard can realign the jaw as you sleep and relieve some of the joint tension.

It’s best to consult with a dentist to get a custom-fit mouth guard because a regular mouth guard isn’t as effective at holding the jaw in place.

Take Pain Relievers

Taking over-the-counter anti-inflammatory pain relievers, such as acetaminophen and ibuprofen, can help relieve TMJ-related ear pain. If the pain is severe enough, a doctor may prescribe muscle relaxers. Applying a warm compress to the jaw can also provide relief.

Get Relief From TMJ-Related Ear Pain

If you suffer from TMJ-related ear pain, call or email the office of Dr. Stein at the Headache & TMJ Center of New Jersey to learn more about what you can do to ease your discomfort.

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769 Northfield Avenue Suite 154
West Orange, NJ 07052

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How to Get Rid of Ear Pain From TMJ

Who Knew TMJ Could Be Such a Pain in the EAR?!

If you are a woman, you are 9 times more likely to experience TMJ pain than a man. One common symptom of TMJ disorder is ear pain and difficulty opening your jaw.

Do you want to learn more about TMJ pain and how to get rid of ear pain from TMJ? Keep reading to learn more about your facial muscles and the tips that will help you restore normal jaw movements without experiencing ear pain. 

Over the counter medications:

One of the easiest things you can do to relieve ear pain from TMJ is to take over-the-counter medication for inflammation. This is a great option because you most likely already have the medicine to help, so you don’t need to get a prescription. 

If you have pain in your ear canal, taking medication like ibuprofen or aspirin can help reduce swelling and ease your pain. 

Self exercises:

When you have ear pain from TMJ, one of the best things you can do to treat this pain is look at the root cause. If you address your TMJ pain, it will likely relieve the pain in your ears as well! Here are a few self exercises you can do on your own to help relieve your TMJ pain. 

First, you can try tucking your chin to your chest to improve your mobility. Simply pull your chin down, essentially creating a double chin, and hold your chin down. Then you can relax and repeat this exercise as necessary. 

Another great exercise you can try is opening and closing your mouth with resistance. Put your thumb under your chin with good pressure. Then, open and close your mouth slowly and work against this pressure. 

These movements can help relieve your pain and prevent ear pain from developing or worsening. 

Massages:

Many people don’t consider when learning how to treat ear pain from TMJ is setting an appointment with a licensed massage therapist. Generally, this pain comes from inflammation, tension, and more. 

Visiting a medical massage therapist can help you relieve this pain and reduce inflammation. In fact, getting a massage can also promote healing in your damaged muscles and relieve any tightness and tension. 

Getting a massage from a licensed massage therapist can also increase your blood circulation. When you have increased blood flow, it reduces your pain and helps you relax. A massage will also help you drain fluid from your ears and will keep it from getting worse. 

While some types of massages you can perform on yourself to help ease pain from TMJ, it is always best to visit a licensed massage therapist. They know the best techniques and can help you find immediate relief!

Additional Resource:

Do you want to know the best ways to treat TMJ? Read: How to Treat TMJ/TMD.

Sucking:

If you are experiencing a lot of pressure in your ears from TMJ pain, something that may help you is sucking on different foods. This can help you relieve pressure and can ease your ear pain. 

Using a straw with your drinks can help. Otherwise, you can suck on hard candy, cough drops, or anything else you have on hand!

Heat and cold:

Using both heating pads and cold packs is a great way to reduce inflammation. If your jaw joint is inflamed, this inflammation can spread up your jaw and up to your ear. Alternating heat and cold can help reduce pain and stop the inflammation from spreading. 

First, use an electric heating pad or some hot pack and leave it on your jaw and ear for about 10 to 20 minutes at a time. Make sure it isn’t too hot, so it does not burn you!

After using heat for 10 to 20 minutes, you can use an icepack in the same area for another 10 to 20 minutes. Whether you have an ear infection or ear pain from TMJ, you will find significant pain relief by alternating these packs several times a day!

Avoid overusing your jaw:

Finally, the best way to get rid of ear pain from TMJ pain is to avoid overusing your jaw. Using your jaw joint too much can cause more pain and inflammation to spread to your ear canal. 

Some things that can lead to a sore jaw joint or TMJ pain are clenching your jaw, grinding your teeth, and even chewing gum! When you open and close your mouth too much, it can lead to your jaw locking up and causing pain when you eat.  

To avoid overusing your jaw, you can try eating soft foods that don’t require too much chewing, avoiding gum and other chewy foods, and you can even do stretches and relaxation exercises to help your jaw relax. 

Learning how to treat Temporomandibular Joint Disorder can help you prevent ear pain from TMJ!

Featured on Virginia This Morning:

Jana Powell recently sat down with Jessica Noll from Virginia This Morning to talk about TMD.

Schedule Your First Appointment Today!

Get Rid of Ear Pain With a TMJ Massage!

When you are experiencing ear pain from TMJ, it can significantly impact your daily life. Whether you go to an ENT specialist, also known as an ear nose and throat specialist, you can significantly reduce and prevent ear pain from TMJ if you follow these tips. 

Do you want to learn how to get rid of ear pain from TMJ? Finding a licensed massage therapist can also help! At Attune Massage Therapy, Jana can help you alleviate TMJ and TMD symptoms with physical therapy, education, and more.   

Contact our TMJ Specialist in Richmond, Virginia today to learn more about our medical massage therapy services.

For more information about Pediatric TMJ Massages, please visit: Pediatric TMJ.

This article should be used for educational purposes only (not advice, diagnosis, or treatment).

Now Offering: Virtual Couples Massage Workshops

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Temporomandibular joint dysfunction as the most common cause of facial pain: current state of the problem

Orofacial pain is widespread in the population. Patients with facial pain seek medical advice from many specialties, including dentists, maxillofacial surgeons, neurologists, internists, and otorhinolaryngologists. Diagnosis of pain in the face can cause a serious difficulty for the doctor.

Pain in the face can be caused by a variety of reasons. In the International Classification of Head and Facial Pain, 3rd revision (ICHD-3 beta), pain syndromes in the facial area are given in Chapter 11 “Headache or facial pain associated with the pathology of the bones of the skull, neck, eyes, ears, nose, sinuses, teeth , oral cavity or other structures of the face and neck” and in chapter 13 “Painful cranial neuropathies and other facial pains” [1]. It should be noted that almost all sections in Chapter 11 use the term “headache (HA)”; only one section mentions facial pain as such (11. 8). Chapter 13 refers to pain syndromes as “neuralgia” or “neuropathy.”

Most of the syndromes listed in the ICGB are not often encountered in the practice of a neurologist. One of the common mistakes in interpreting the cause of facial pain is the overdiagnosis of trigeminal neuralgia (TN) followed by prolonged and ineffective treatment with carbamazepine. At the same time, TN has been shown to be a relatively rare cause of facial pain [2].

This article focuses on temporomandibular joint dysfunction (TMJD). Today, TMD is regarded as the most common cause of chronic facial pain not associated with dental disease [3]. Facial pain associated with pathology in the region of the temporomandibular joint (TMJ) occurs in 19—26% of the adult population, and in women it is observed 1.5 times more often than in men [4, 5].

Clinical picture

Patients with TMD may experience pain in the face, maxilla and mandible, neck and shoulders, and in and around the ear. The pain may be constant or appear when chewing, talking, opening the mouth. Often the pain is also accompanied by a feeling of tiredness in the face and swelling.

In addition to facial pain, patients may experience headache, neck pain, earache, toothache, burning and stabbing sensations in the face, and shooting and puncture sensations. In addition to pain, there are also more rare and therefore even more difficult to diagnose symptoms: noise, ringing or congestion in the ears, non-systemic dizziness, and even itching or tingling in the head and neck. Pain may develop gradually, but many patients report an abrupt onset of pain and accompanying symptoms.

Difficulty chewing, inability to open the mouth wide, crackling/clicking when opening or closing the mouth, and blockage of the mandible are all indications of damage to the TMJ itself and facilitates diagnosis.

Diagnostics and differential diagnostics

Previously, TMD was considered exclusively as a pathology of the TMJ and as a consequence of subluxation of the lower jaw, arthritis, arthrosis or trauma of the TMJ, as well as occlusal disorders [6, 7]. However, in 2014, the TMD Diagnostic Criteria for Clinical Practice and Research (DC/TMD) was adopted by the International RDC/TMD Consortium Network and Orofacial Pain Special. interest group). In accordance with these criteria, TMD is divided into two groups: pain and intra-articular pathology; their combination is also possible [8].

A large number of patients with TMD have a painful form, i.e. pain in the area of ​​masticatory muscles, while the pathology of the joint itself is not detected. The literature describes pain in the face associated with myofascial dysfunction of the facial muscles [7, 9]. The authors indicate that during palpation of the muscles on the side of pain, a dense texture and muscle tension, especially masticatory and facial muscles, as well as severe pain and myofascial trigger points, were noted. On palpation of the masticatory muscle, the pain spreads to the upper and lower jaws, upper and lower molars, to the ear, to the frontal region, to the TMJ, to the neck. On palpation of the temporal muscle, pain radiates to the corresponding half of the head, forehead, upper teeth, and orbit. Since the prevalence of the painful form of TMDJ exceeds the prevalence of the intra-articular form [10], most patients can and should receive effective care from a neurologist. Thus, facial pain in a patient is most often caused by hypertonicity and myofascial pain syndrome in masticatory muscles without pathological changes in the structures of the joint itself.

When a patient presents with facial pain, a neurologist needs to conduct a proper examination (palpation) in order to diagnose and optimally treat such patients. This will avoid unnecessary referral of patients to dentists and ENT doctors and unnecessary and often painful examinations.

New criteria for the correct diagnosis of TMD are presented in the table.

Criteria for the diagnosis of TMD DC/TMD for use in clinical practice and research (adapted from [8])

Thus, according to the diagnostic criteria for TMD for clinical use, pain disorders are not associated with the pathology of the TMJ itself and can be represented by myalgia, arthralgia and HT associated with TMD. These criteria are based on the data of the anamnesis and clinical examination (palpation of the temporal and masticatory muscles) and do not require mandatory imaging studies. In myalgia, pain may be felt in the jaw, temple, ear, or anterior to the ear and usually changes with mandibular movement, chewing, or parafunctional activity. This means that pain in the face, ear, anterior and near the ear, as well as tinnitus may be symptoms of TMD and not indicate the presence of ENT pathology.

In the case of local myalgia, the pain felt by the patient is reproduced by palpation of the temporal and masticatory muscles within their palpable area. In myofascial pain syndrome, pain extends beyond the palpable area within or outside the palpated muscle (myofascial pain syndrome with referred pain).

It should be noted that for a complete diagnosis, it is necessary to follow the correct muscle palpation protocol: 3 points in the temporal muscle (anterior, middle and posterior sections) and 3 points in the masticatory muscle region (the beginning of the muscle, its body and its attachment site) [11]. Palpation is carried out with one or two fingers on each side separately or on both sides at once (depending on the convenience of the patient), the duration of pressing to determine myalgia should be at least 2 s, if it is necessary to determine the subtype of myalgia, at least 5 s. In practice, it is also possible to palpate the masticatory muscle by pressing it with the researcher’s thumb in the patient’s mouth and with the rest of the fingers outside.

To determine the presence of arthralgia, it is necessary to confirm that the pain felt by the patient in the face is localized in the TMJ region and is reproduced during provocative tests: palpation in or around the condylar process of the mandible or with maximally active or passive mouth opening, lateral movement or protrusion of the mandible .

In the case of localization of pain in the parotid region anterior to the auricle, it can be difficult for the clinician to determine the specific structure involved. In this case, it is necessary to determine whether the pain is localized in the region of the condylar process of the lower jaw (arthralgia) or the masticatory muscle. In the latter case, one of the types of myalgia will be diagnosed. To determine the location of the condylar process of the jaw and confirm the source of pain felt by the patient, it is necessary to palpate the anterior region with the mouth closed. In case of difficulty, palpation should be performed when opening the mouth or protruding the lower jaw forward (Fig. 1).

Rice. 1. Palpation to locate the condylar process of the mandible. a – with a comfortable closing of the mouth; b – with protrusion of the lower jaw.

To find the points of palpation of the masticatory muscle, ask the patient to clench and then unclench his teeth. In this case, the definition of the boundaries of the palpated muscle is greatly simplified (Fig. 2).

Rice. 2. Palpation of the masseter muscle to determine the form of TMD. a – the place of the beginning of the muscle; b – muscle body; c — zone of muscle attachment.

Palpation of the temporal muscle is much easier. It is necessary to palpate at least 3 points in the anterior, middle and posterior portions of the muscle (Fig. 3). In case of difficulty in finding the boundaries of the temporal muscle, it is necessary to ask the patient to clench his teeth.

Rice. 3. Palpation of the temporal muscle in order to determine the form of TMD. a – anterior portion of the muscle; b – the average portion of the muscle; in — a back portion of a muscle.

Another type of pain form of TMD is TMJ associated with TMD. In ICHD-3, beta HT associated with TMD is referred to as secondary cephalalgia and is described as “HT caused by a disorder involving structures in the TMJ area” [1]. The first two items are non-specific criteria confirming the secondary nature of the pain; only item 3 contains TMD-specific characteristics: GB is provoked or exacerbated by active jaw movements, passive movements in the usual range of jaw mobility, and/or provocative tests with temporomandibular structures, such as pressure on the TMJ and surrounding masticatory muscles. However, the commentary on the diagnostic criteria contains a recommendation from the International Headache Society to use newer and more accurate criteria developed by the RDC/TMD International Network Consortium and the Orofacial Pain Research Group to fully diagnose and clarify the causes of pain associated with TMD.

Differential diagnosis of HT associated with TMD includes other forms of primary and secondary cephalgia. When conducting a differential diagnosis, it is necessary to rely on the known diagnostic criteria for these cephalalgias. In the case of strictly unilateral HA, it is necessary to exclude migraine and cervicogenic GB. Patients with migraine are characterized by provocateurs of a painful attack that are not typical for TMD, migraine symptoms accompanying an attack (nausea, vomiting, phono- and photophobia), often a hereditary history of G.B. To confirm the diagnosis of cervicogenic HA, rotational tests and diagnostic blocks of cervical structures are used [1]. In the case of bilateral localization of pain, difficulties may arise in the differential diagnosis with tension headache, combined with tension of the pericranial muscles. In this case, the inspection and palpation shown in Fig. 1-3 are of key importance for diagnosis.

Intra-articular forms of TMD are somewhat less common in the practice of a neurologist. It should be noted that in many cases the identified intra-articular pathology is combined with the pain form of TMD and is not isolated.

In the presence of damage to the TMJ itself, there are several forms of TMD. With various forms of displacement of the intraarticular disc with reduction, different intracapsular sounds are noted during palpation of the joint and movements of the lower jaw: crunching, crackling, clicking. Disc displacement without reduction is usually caused by spasm of the lateral pterygoid muscle [12]. When the disc is displaced without reduction, there is a pronounced restriction of mouth opening and a violation of the ability to eat. In the case of degenerative pathology of the disc, a coarser (similar to grinding) and long sound can be noted – crepitus caused by friction of the damaged intraarticular disc. Blockage of the TMJ when the mouth is open and the inability to close the mouth without an assisted maneuver are indicative of mandibular subluxation.

Examination rules for the diagnosis of intra-articular form of TMD are shown in fig. 4. To confirm the diagnosis of various intra-articular forms of TMD, it is necessary to conduct an MRI examination of the joint.

Rice. 4. Palpation aimed at detecting sounds in the TMJ. a — when opening/closing the mouth; b – lateral movement of the jaw to the right; c – lateral movement of the jaw to the left; g – protrusion of the lower jaw. Palpation is carried out sequentially on each side.

Etiology and pathogenesis of TMD

The etiology of TMD is multifaceted and is a combination of psychological, postural, orthopedic, genetic, biopsychosocial and occlusive factors that disrupt the functional balance in the structures of the TMJ itself and the surrounding muscles [6, 13, 14].

The view on the pathophysiology of TMD cannot be considered finalized. In 1934, James Costen gave the first systematic description of this group of diseases, indicating occlusion failure as the main cause. For many years, it was believed that the cause of myogenic and articular disorders in TMDJ is malocclusion (occlusal disorders, missing teeth, suboptimal prosthetics, chewing on one side and other causes) and parafunctional activity (night and/or daytime bruxism), which leads to increased load on the TMJ and muscles that provide chewing (temporal, chewing, medial and lateral pterygoid). A significant role was also assigned to injuries of the face and lower jaw and emotional disorders. In particular, the presence of symptoms of depression doubles the likelihood of developing the arthralgic form of TMD, and anxiety disorders often accompany myalgia in TMD [15, 16]. Some authors [7] point to the role of orthopedic disorders (for example, short leg syndrome) in the genesis of TMD. An orthopedic examination in a significant number of patients (66%) reveals asymmetries of the shoulders, shoulder blades, shortening of one leg, which causes a compensatory change in posture and muscle imbalance throughout the entire spine. The “forward head posture” also has a serious influence on the occurrence of the myogenic form of TMD [17].

However, in recent years, a number of authors have expressed doubts about the exclusive role of dental pathology in the development of TMD. Point to the frequent combination of TMD and various types of GB. In patients with TMD, the most common primary form of HA is migraine (55.3%), the prevalence of HA is 30.2% [18]. According to other authors [19], the prevalence of TMD in patients with chronic daily HA is 58.1%.

In recent years, in the works of leading Russian and foreign researchers of chronic pain [20—22], for the first time, suggestions were made about possible central causes of TMD, in particular, about the role of a possible dysfunction of pain control systems. Thus, it has been shown that the prevalence of the pain form of TMD in chronic migraine significantly exceeds that in episodic migraine. The authors hypothesized that pain and myofascial pain syndrome in TMD may be caused by impaired processing of pain impulses in the CNS and are not associated with peripheral/dental factors.

Treatment

Based on the current understanding of the pathophysiology of TMD, a range of treatments have been developed. In neurological practice, TMD treatment includes a wide range of non-drug and pharmacological approaches:

1. Patient education. Educating patients about the causes and form of TMD and the importance of behavior modification (eg, actively focusing on not clenching teeth) is important. In case of acute pain, it is necessary to recommend a temporary refusal to eat solid food and open the mouth wide.

2. Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first choice and are effective in managing TMD pain. Among a large group of NSAIDs, the drug nimesulide (nise) deserves special attention. The difference in clinical efficacy and tolerability of different NSAIDs may be due to different selectivity for inhibition of COX-1 and COX-2. Nimesulide is predominantly a COX-2 inhibitor with a wide range of additional actions, which helps to explain its specific anti-inflammatory and analgesic activity. More than 200 clinical studies have evaluated the effectiveness of nimesulide in a wide range of pain syndromes (tooth extraction and other dental operations, GB, back pain, joint pain, dysmenorrhea). In these studies, nimesulide systematically demonstrated a reduction in inflammatory pain significantly superior to placebo and at least equal to or in some cases even more effective than other NSAIDs [23].

The main clinical benefit of nimesulide is the time to onset and duration of pain relief. Compared with other NSAIDs, nimesulide has a faster onset of analgesic action, namely 15 minutes after ingestion [24], it should also be noted that a rapid onset of action was noted in patients with chronic pain syndrome.

A significant advantage of this drug is a lower relative risk of complications of the upper gastrointestinal tract compared with non-selective NSAIDs due to the predominant effect on COX-2. However, a single dose of nimesulide provided higher efficacy and a faster onset of analgesia than comparable single doses of selective COX-2 inhibitors such as celecoxib and rofecoxib [25]. When comparing nimesulide with the non-selective NSAID diclofenac, the drug showed comparable efficacy, but better overall tolerability [26].

The overall risk of severe liver reactions associated with the use of NSAIDs is low. The incidence of liver damage associated with the use of nimesulide is within the frequency range for other NSAIDs [23].

The use of all NSAIDs is associated with some cardiovascular risk and in patients with arterial hypertension, hypercholesterolemia and cardiovascular disease, all NSAIDs should be used with caution, especially in the elderly. Risks and benefits should be assessed on an individual basis and the lowest effective dose is recommended for the shortest possible period of time. Many data indicate that nimesulide demonstrates a low overall risk of cardiovascular events such as myocardial infarction or congestive heart failure [27].

An international panel of experts concluded that, when used appropriately, nimesulide remains an extremely important and safe treatment option for various conditions characterized by the presence of acute inflammatory pain, due to the rapid onset of analgesic action and a proven positive benefit/risk profile [23].

Nise is recommended for TMD at a dose of 100 mg twice daily. The duration of its use, like other NSAIDs, should be limited to the minimum necessary time.

3. Gymnastics . After applying a cold compress, exercises are performed to stretch the masticatory muscles, then a warm towel must be applied.

4. Cognitive behavioral therapy and biofeedback are also highly effective.

For chronic TMD it is recommended:

1. Administration of the tricyclic antidepressant amitriptyline (up to 75 mg/day). The choice of amitriptyline as a first-line drug is due to the relatively high risk of developing bruxism while taking selective serotonin reuptake inhibitors [28].

2. Referral of the patient to the dentist for the selection of a special muscle relaxant splint (especially in the case of nocturnal bruxism) and assessment of the presence and correction of occlusal disorders.

3. In case of myofascial pain syndrome, it is possible to inject anesthetic into trigger points in masticatory, temporal and pterygoid muscles.

4. Treatment with botulinum toxin type A for the painful form of TMDJ, which has demonstrated high efficacy in a large number of studies [9, 29]. Such therapy can not only achieve long-term and sustainable relaxation of the muscles of the masticatory group and relieve pain associated with myofascial pain syndrome in these muscles, but also a temporary remission of nocturnal bruxism, which will reduce the risk of developing an intra-articular form of TMD.

5. Carrying out complex treatment of comorbid diseases, in particular depression, anxiety disorders, chronic pain.

6. In case of proven presence of intra-articular form of TMD, dysfunction of the jaw and lack of effect of conservative therapy, the patient should be referred to an oral surgeon [30].

TMD is considered today as the most common cause of chronic facial pain not associated with dental disease. It has been shown that facial pain in many cases is caused by hypertonicity and myofascial syndrome in masticatory muscles without pathological changes in the structures of the joint itself. Since the prevalence of the pain form of TMDJ exceeds the prevalence of the intra-articular form, most patients can and should receive effective care from a neurologist. For a complete diagnosis of the nature of TMD, one should rely on the DC/TMD diagnostic criteria for clinical use. These criteria are based on the history and clinical examination (correct palpation of the temporalis and masticatory muscles) and do not require mandatory imaging studies. If typical symptoms of intra-articular pathology (primarily sound) are detected, an MRI of the joint is indicated to confirm the diagnosis.

TMD is currently considered a disease with a multifactorial etiology. Myofascial pain syndrome in the muscles of the masticatory group can be considered as a manifestation of a violation of antinociceptive functions, i.e., it is a reflection of central sensitization and a violation of downward pain control.

Treatment of the painful form of TMD at the first stage should be carried out by a neurologist. Recommendations for the treatment of TMD include patient education, NSAIDs, cognitive behavioral therapy, and biofeedback. For chronic pain, amitriptyline, injections of anesthetics and botulinum toxin type A, and referral to a dentist and maxillofacial surgeon are also possible.

The authors declare no conflict of interest.

Treatment of TMJ

Dysfunction TMJ is a functional pathology of the temporomandibular joint caused by muscular, occlusal and spatial disorders. TMJ dysfunction is accompanied by pain syndrome (pain in the head, temples, neck), clicks in the joint, limited mouth opening amplitude, noise and ringing in the ears, dysphagia, bruxism, snoring, etc. The method of examining patients with TMJ dysfunction includes the study of complaints, analysis of gypsum models of the jaws, orthopantomography, radiography and tomography of the TMJ, electromyography, rheoarthrography, phonoarthrography, etc. Treatment of TMJ dysfunction is carried out taking into account the causes and may include grinding of supercontact teeth, proper prosthetics, bite correction, wearing a cap or joint splint, surgical treatment .

Symptoms dysfunction TMJ

Currently, the following groups of symptoms are considered to be diagnostic criteria for TMJ dysfunction:

1. Sound phenomena in the temporomandibular joint. The most common complaint of patients with TMJ dysfunction is clicks in the joint that occur when opening the mouth, chewing, yawning. Sometimes the clicking can be so loud that people around you can hear it. In this case, pain in the joint area is most often absent. Other noise phenomena may include crunching, crepitus, popping sounds, etc.

2. Blocking (“locking”, “jamming”) of the temporomandibular joint. It is characterized by difficulty in moving the joint when opening the mouth. That is, when trying to open the mouth wide, the patient needs to make movements with the lower jaw from side to side, to catch the optimal position of the lower jaw, finding the point where the joint “unlocks”.

3. Pain syndrome. There are no sensitive endings in the joint itself and therefore pain appears in the trigger zones: masticatory, temporal, hyoid, cervical, pterygoid, sternocleidomastoid, trapezius muscles. Facial pain, headaches, earaches, toothache, pressure and pain in the eyes are common. Pain in TMJ dysfunction can mimic trigeminal neuralgia, cervical osteochondrosis, TMJ arthritis, otitis media, and other diseases.

4. Other symptoms. TMJ dysfunction may include dizziness, sleep disturbance, depression, nighttime teeth grinding/clenching, tinnitus or ringing, dry mouth, tongue sensitivity/burning, snoring, etc.

TMJ leads to diagnostic difficulties, so patients can be examined for a long time by a neurologist, otolaryngologist, therapist, rheumatologist and other specialists. Meanwhile, patients with TMJ dysfunction need the joint cooperation of a dentist and a neurologist.

During the initial examination of the patient, complaints, anamnesis of life and disease are clarified, palpation and auscultation of the joint area is performed, the degree of mouth opening and lower jaw mobility is assessed. In all cases, impressions are taken for the subsequent manufacture of diagnostic models of the jaws, occludedograms are performed, and functional tests are carried out in order to determine the optimal position of the jaw.

To assess the state of the temporomandibular joint, orthopantomography, ultrasound, X-ray of the TMJ, and computed tomography of the TMJ are performed. In order to detect damage to the periarticular soft tissues, MRI of the temporomandibular joint is indicated. Determination of indicators of arterial hemodynamics is performed by dopplerography or rheoarthrography. Of the functional studies in TMJ dysfunction, electromyography, phonoarthrography, gnathodynamometry are of the greatest importance.

Treatment dysfunctions TMJ

During the main treatment period, patients with TMJ dysfunction need to reduce the load on the temporomandibular joint (eating a soft consistency, limiting speech load). Depending on the causes and concomitant disorders, various specialists may be involved in the treatment of TMJ dysfunction: dentists (generalists, orthopedists, orthodontists), chiropractors, osteopaths, neurologists, psychologists.

To eliminate the pain syndrome accompanying TMJ dysfunction, pharmacotherapy (NSAIDs, antidepressants, sedatives, botulinum therapy, blockades, intra-articular injections of glucocorticosteroids), dosed myogymnastics, massage, physiotherapy (laser therapy, inductothermy, electrophoresis, ultrasound, etc. ) are indicated. Important elements of complex therapy can be psychotherapy and biofeedback therapy, allowing to achieve functional relaxation of the masticatory muscles.

Dental treatment of TMJ dysfunction according to indications may include measures aimed at restoring the correct closure of teeth (selective grinding of teeth, removal of oversized fillings, competent prosthetics or reprosthetics, etc.). To correct malocclusion, treatment is carried out with the help of braces. In some cases, orthopedic and orthodontic treatment of TMJ dysfunction with fixed appliances is preceded by wearing orthopedic splints or caps.

If conservative treatment of TMJ dysfunction fails, surgical intervention may be required: lateral pterygoid muscle myotomy, condylotomy of the mandibular head, arthroplasty, etc.

Prognosis and prevention of TMJ dysfunction

Treatment of TMJ dysfunction is mandatory. Neglect of this problem can be fraught with the development of dystrophic changes (arthrosis) and immobilization of the temporomandibular joint (ankylosis).