Timothy C. Hain, MD Page last modified: May 18, 2018
See also: Dizziness and dental work
TMJ stands for the temporomandibular joint. The TMJ is located just below the Eustachian tube. TMD stands for temporomandicular dysfunction. It basically means something is off with the TMJ.
|Location of the Eustachian Tube. The TMJ is just below the ear and ET tube.|
Because the TMJ is a joint, it can become arthritic. Because people use it all the time (to talk and eat), arthritis is very common. Because it is close to the ear, pain in the TMJ can feel as if it is coming from the ear.
With all of that background aside, the TMJ is blamed for an immense number of human ailments. One dentist, apparently trying to drum up business, sent me a circular claiming that TMJ causes:
Supposed consequences of TMJ
- Neck, shoulder and back pain
- Jaw joint aching and or facial pain
- Ear congestion, tinnitus, loss of hearing, or hyperacusis
- Clicking or popping noises with jaw movement.
- Locking open or closed, painful while chewing
- Pain behind the eyes, dizziness
- Difficulty swallowing.
Some of these are reasonable -- jaw joint aching for example. Some are implausible. I have also been contacted by a group of dentists who were upset that I questioned the association between TMJ and a myriad of other symptoms. I asked them for data in the form of peer reviewed publications. These were not provided, but this probably reflects the lack of diligence of these dentists rather than a lack of data, as Pubmed has large numbers of papers, largely written by dentists, concerning the association between TMD(TMJ) and many ear complaints.
Because most dental work is "out of pocket", we have a situation here where charismatic dentists can make a good income by selling unproven treatments to patients. Of course, it is the patient's money and they can spend it on whatever they please, but one should understand that the risks of this process are high.
Pubmed has more than 500 papers on the association between TMJ and various otologic problems. Salvetti et al (2006) commented that "Unfortunately, methodological weaknesses of most studies are evident so that the comparison of results is often difficult."
Cox (2008) investigated ear related symptoms in persons with TMD (temporomandibular dysfunction - -same as TMJ). He reported much higher occurrence of the following symptoms:
|warm and/or fluid sensation||38|
|loud noise sensitivity||6.2|
|pressure or fullness||6.2|
|cold air/wind sensitivity||4.4|
|brief dizziness spells||3.5|
|ringing or other noises (tinnitus)||2.8|
Similar to Cox, Lee et al (2016) reported a 2.73 increased hazard ratio for tinnitus in TMD patients. Akhter et al found even higher odds ratios in Japanese young adults. So the association with tinnitus is probably real. Fullness was also found by Porto de Toledo et al (2016) to be associated with TMD.
Some of these symptoms could simply be related to focusing of attention on the painful ear. If one's ear is hurting, it seems reasonable to also start to pay more attention to symptoms that might be due to the ear - -such as ringing, dizziness, or pressure. These symptoms could also be caused by the TMD.
Regarding dizziness, Porto de Toledo et al (2016) also reported vertigo in 40.8%. It seems very unlikely to us, however, that any substantial dizziness is caused by TMJ/TMD, and it also seems highly unlikely to us that TMD causes any organic changes in auditory processing. Rather, we think that this association is probably psychological in origin, and related to a redirection of attention.
Concerning hearing loss, Effat (2016) reported an association 104 TMJ patients with 110 control patients. Amazingly enough, "Twenty-five per cent of unilateral or bilateral temporomandibular disorder patients had either unilateral (ipsilateral) or bilateral hearing loss; respectively, which was usually mild (p = 0.001). Hearing loss was predominantly sensorineural." Porto de Toledo et al (2016) also reported hearing loss in 39%. Because the TMJ is just a joint and the ear is a sensory organ, we find this data amazing. We would wonder if there might be a confounding variable.
There is an amazing repertoire of treatments for TMJ -- dental appliances, orthodontic work, physical therapy, surgery, botox injections. A common feature of most of these treatments seems to be that they are expensive. A rather simple "bite guard", often provided by dentists -- costs about $300-500 in Chicago. MRI or CT of the TMJ, followed by orthodontic appliances is at least an order of magnitude more expensive. We have heard many times of a local dentist who performs a series of expensive x-rays, fits patients with a very expensive appliance, and is sad when it doesn't work.
Some of these treatments that do seem to help -- for example,
- Bite appliances that reduce grinding, seem to be commonly helpful.
- Botox seems logical for the muscle spasms (it lasts for 3 months). Botox, of course, is not approved for this use and is rarely covered by insurance. Still, if you can find someone to do it, might be worth trying.
On the other hand:
- So far, we have not encountered any patients who indicate that orthodontic work has helped their TMJ.
- We have encountered many patients who indicate that TMJ surgery failed (this is rarely done these days).
Unusual treatments (perhaps placebos)
- Physical therapy -- massage from the inside. Perhaps helpful if the patient learns how to do this.
- TMJ joint injections -- with local anesthetics or "anti-inflammatory" -- presumably steroids
- Trigger point injections -- around the jaw. Hard to see why this would last.
- Nerve blocks -- seems reasonable for diagnosis
- Prolotherapy -- injections of sugar and water -- to us it seems very unlikely that injections of sugarwater into the TMJ will be helpful.
- Nerve ganglion blocks: sphenopalatine, otic, submandibular. It is hard to see how this would cause any lasting effect, but perhaps might help with diagnosis.
- Appliances that "distract" the Jaw -- move jaw away from the joint. Perhaps there is some logic to this. Not sure about any data.
Be careful when you see TMJ specialists - -get a second opinion. If a TMJ practitioner proposes to sell you a device, be cautious.