Learning with laughter

True Stories

February 17th, 2013

The stories that follow are about real people and their jaw -related health problems. While the individual stories are unique , the health problems and final solutions are not.

To give some background about TMD, it is not age related. A study recently by the Dental Clinics Of North America [Dent Clin North Am] 2013 Jan; Vol. 57 (1), pp. 99-127.) found that a child’s difficulty in verbalizing the precise location and nature of facial pain and jaw dysfunction often results in a nondefinitive history, increasing the importance of the dentist’s awareness of the early signs and symptoms of temporomandibular joint disorders (TMD). A focused examination of the masticatory musculature, the temporomandibular joints, and associated capsular and ligamentous structures can reveal if a patient’s symptoms are TMD in origin. An accurate differential diagnosis enables timely referral to appropriate health care providers and minimizes the use of diagnostic imaging.

This story highlights the effects of a dental crossbite and ear symptoms

Baby Clare was about 4 months when she had her first ear “infection”. She went on to have over 20 ear problems in just 2 years. Initially the ear problems were thought to be related to teething which puts undue forces on the jaws joints, ears and Eustachian tubes. However the problems seemed to be more on the right side. She was frequently put on antibiotics which resolved symptoms in 7 days but then re appeared.

(Acute otitis media (AOM) is one of the most common diseases in early infancy and childhood. Antibiotic use for AOM varies from 56% in the Netherlands to 95% in the USA, Canada and Australia).

In addition Baby Clare had difficulties nursing  because of a stuffy nose making it impossible to stay latched on while breast feeding. This was exhausting for mother and baby because Clare was constantly hungry and crying. They also wondered why she cried more when they laid her down on the right side. No amount of rocking and walking in the pram seemed to placate her for long periods! The stuffy or runny nose persisted, and at the age of 2 she was tested for milk allergies. This was inconclusive. 

Her Dad, a dentist noticed that she had a very narrow upper jaw-palate. The teeth had erupted into her mouth in what is called a Right Dental Crossbite. This meant that her jaw shifted toward the right side and ear. He decided to take matters into his own hands and made a dental plastic bonding material to change and balance out the bite and stop the jaw from shifting toward the right ear.  Since then,she did not have another ear “infection” or problem with a stuffy nose!

A study written up in radiology literature (Radiology.  182(2):531-4, 1992 Feb.) is interesting

Thirty-two children were evaluated by means of medical history and physical examination for signs and symptoms of internal derangement (ID) of the temporomandibular joint (TMJ) and mandibular dysfunction. These children also underwent magnetic resonance (MR) imaging of the TMJs. The study was double blind. At clinical examination, 19 patients (59%) had at least one positive finding of ID of the TMJ and/or mandibular dysfunction. MR images of the TMJ obtained in 60 of the 64 TMJs demonstrated 57 normal joints (95%) and three abnormal joints (5%). Two of these three joints had a mild anterior-lateral disk displacement, and one joint had an anterior dislocated disk. There were no false-positive MR examinations. MR imaging failed to depict abnormalities in 16 patients who had positive findings at history and/or physical examination. Although MR imaging may fail to depict ID of the TMJ in some patients, clinical techniques commonly used in population surveys probably overstate the prevalence of ID of the TMJ in children.

Physiotherapists can also play a role in early detection. Currently the symptoms of TMD are misdiagnosed or poorly understood.

In a study done by The British Journal Of Oral & Maxillofacial Surgery [Br J Oral Maxillofac Surg] 2013 Jan; Vol. 51 (1), pp. 52-7. Date of Electronic Publication: 2012 Apr 26.

It states: Up to a quarter of the general population has experienced temporomandibular joint disorder (TMD) at some point in time. Physiotherapy has been used in the management of TMD for many years, but evidence supporting its clinical effectiveness is limited. Questionnaires were sent to 356 OMFS consultants listed on the British Association of Oral and Maxillofacial Surgeons’ website. A total of 208 responded (58%) and 72% considered physiotherapy to be effective.

65-85% of US experience TMD at some point in their lives. 12% sever enough to receive treatment

Second True Story

Is it your parotid Gland or the Jaw?

Last Christmas Eve is one Stan will never forget. After weeks of coughing and sneezing following a cold and sinus infection, he woke up, yawned and was unable to close his mouth. He was terrified. Also his teeth on the left side were not touching and chewing gave him a sharp pain on the left side of his head.  The doctor diagnosed a parotid gland infection and prescribed a course in antibiotics. An xray done on the left jaw was unremarkable.

Prior to this moment Stan had no conscious issues with his jaw. In fact he had degenerative changes that silently progressed for years.  No one considered the possibility that the chronic headaches and  sinus congestion was connected to a TM Joint dysfunction. Sinus surgery had been suggested to “chisle it out” but due to multiple health issues, including atrial fibrillation he decided against having surgery.

On examination, Stan was in distress. He thought his bite was “off” as he kept biting the inside of his cheek. He had not slept in days as it was painful to sleep on *his right side*, and assumed he had developed an ear infection because it felt “full or plugged”. He also felt his Balance was not as good as it usually is

(See end of article for possible reason-The TMJ is a “Barometer for Balance” as well as being used for chewing , talking and swallowing)

* Having a preferred side to sleep on is often related to inflammation of a TM Joint ligament, which being near the ear will make the brain think it is an ear problem. As the function of ligaments is to act as passive restraining devices to limit and restrict joint movement.(ie: It helps prevents extensive forward, backward and lateral movement) , It will be comprimised if the disc is displaced forard laterally or medially.*

On palpation, he had pain in his facial chewing muscles and inside his ear. Crepitus could be felt when he moved his jaw side from side to side.

After examining his neck and jaw, I diagnosed  an acute capsulitis and a disc displacement of the left TMJ area with resulting dental malocclusion.  (Dental occlusion refers to the way your teeth meet when you bite together, chew and swallow)

To reduce the inflammation the dentist prescribed Diclofenac which is an anti inflammatory cream which is massaged into his cheek daily. Sadly Stan like most people do not realise that if applied too much, one can develope a rash which added more discomfort. This is what happened. Oral anti inflammatories upset his stomach. This Christmas was getting worse instead of better.

If you know anyone like Stan, with the following symptoms, please help them see a health professional that understands and can help? There can be many reasons for headaches but if they are associated with any of the following he suspicious of a Jaw Issue.

  • Chronic headaches
  • Ringing in the ears
  • Ear congestion
  • Facial pain
  • Jaw pain
  • Clenching & grinding teeth
  • Dizziness
  • Shoulder/back pain
  • Limited jaw opening or locking jaw.

Stan had been given an xray to determine a joint problem. As most people know, X-ray and MRI exposes you to radiation and are costly. They to do not provide statistically as consistantly accurate diagnosis as Joint Vibration Analysis (JVA).   A set of sensors is placed over the TMJ. as you open and close your mouth. The sensors pick up the vibrations coming from the TMJ on each side.  The data can be analysed to produce a very accurate understanding of the pathology of the joint.  The whole tests take approximately 5 minutes.

Unfortunately most doctors and dentists are unaware of the availability of this test.  The traditional alternative methods of diagnosis involve palpating muscles and feeling for movement by placing fingers in your ears.

The TMJ is the most complex joint in the body. In addition it is complex how the body compensates for any dysfunction. As a result TMJ is poorly understood and misdiagnosis of poor jaw mechanics is a common problem for patients who have facial pain. Education is key for every health professional to consider all the options but in my opinion, the jaw joints should be near the top of their list

Please note:* Up to 75% of the population has at least one sign or symptom of temporomandibular (TM) dysfunction at any given time and 34% of the population reports a temporomandibular disorder.

For any health professional reading this story, the TMJ anatomy is key to understanding of its complexity. Dr Steve Olmos a leading authority on TMJ writes:

The TMJ is composed of the condyle (mandible) and the articular (or glenoid) fossa of the temporal bones, bilaterally. the temporal bone consists of five parts: squamous, petrous, internal acoustic meatus, zygomatic, and middle cranial fossa. The facial nerve (motor control ove rthe facial muscle) and the vestibulocochlear nerve (balance and hearing) both travel the course of the internal acoutic meatus. the middle cranial fossa is the floor, which supports the brain stem from which the cranial nerves originate.

The connection between the TMJ and the middel ear is through the petro-tympanic fissure. This runs the length of the glenoid fossa.

Everything is connected! Christmas 2013 is long gone but Stan will never forget it.



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