THE TMJ TRAP
Most headache sufferers go from doctor to doctor looking for some kind of answer. Each new physician or therapist 'knows' our problem and proceeds to treat us accordingly.
During our quest for pain relief, many of us have been told we have 'TMJ', a disorder of the jaw joint. So we visit a dentist who specializes in temporomandibular joint dysfunction (TMJ). 'Temporo' refers to the temple bone of the skull, mandibular refers to the lower jaw (i.e., the mandible), and the joint is where the two meet, just in front of the ear canal. The TMJ practitioner attempts to treat all the parts that control chewing: the teeth, the jaw joint, and the muscles.
In TMJ treatment, two particular theories attempt to explain why we have headaches. The first concerns the manner in which the upper and lower teeth meet, or 'bite', called the occlusion. Some TMJ practitioners feel that an improper bite is the cause of the headache pain. They believe that patients with a bad bite are constantly straining the jaw muscles (including the temporalis) to hold the lower jaw in such a position to create a proper bite. This strenuous activity results in myofascial (i.e. muscular) dysfunction, displayed as headaches. The TMJ practitioner's solution is to alter the teeth (by either orthodontics, crowns, grinding of the teeth, surgery, or some combination) to obtain the proper bite. The second theory assumes that the jaw joint itself is somehow damaged, which ultimately causes headache pain. The headache occurs when the muscles that surround the damaged joint assume a tightened (contracted) posture, in order to protect and support the damaged joint. If the joint is found to be irreversibly damaged, specialized therapy and surgery are recommended. Both theories utilize identical initial treatment. A special mouthpiece, called a splint, is fitted to the upper or lower teeth and covers the back molars and the edges of the front teeth.
The biting surface of the splint is polished smooth and flat, so that after you bite on it, your jaw can slide around. The design of this splint, often referred to as a 'flat plane' splint, serves two purposes. First, by preventing the opposing teeth from coming together in an improper bite, the jaw muscles can supposedly relax and allow the lower jaw to slide on the splint to the jaw's most optimal position. This would allow the muscles to 'heal'. Therefore, the splint should have eliminated the "bite" as a cause of the headache. Second, the splint prevents the jaw from closing all the way by keeping the opposing teeth separated by the thickness of the splint. Some practitioners believe that this will relieve pressure in the jaw joint. Therefore, those practitioners who diagnose jaw joint damage as the cause of the headaches believe that if pressure and strain are relieved from the joint, the joint will 'heal', which will allow the muscles to relax and resolve the headaches…but when using the traditional splint that is a very questionable "if".
The lateral pteryogoid muscle is what pulls the jaw from side-to-side and forwards, and is the muscle that experiences relief when splint therapy is successful.
Most patients who have mild to moderate headaches typically respond well to splint therapy; however, those who suffer with moderate to severe headaches don't do as well. As weel over half of the patients with severe headache symptoms who are treated with TMJ splints, experience no relief or feel worse. Unfortunately, I was in this category, wearing a splint for five years with no relief.
There are situations in which TMJ therapy is indicated. Occasionally, in addition to their headaches, patients do have sore, tender, or painful jaw joints. Their jaws may move to the right or left or zigzag when opening and/or closing. Their jaw joints may make popping, clicking, or grinding sounds. Patients who experience these symptoms along with their headaches are often advised to try physical therapy, biofeedback, and chiropractic care in addition to their TMJ splints. If these methods are ineffective, patients may be referred to a counselor to help deal with life's stress. If these therapies and the splint wear have proven to be ineffective (i.e. the pain persists), surgery is often recommended. The most common TMJ surgical procedure simply 'rinses out' the joint space, flushing out the entrapped residue of inflammation and allowing the joint to heal, thereby allowing muscles to relax and curing the headache. Unfortunately, some patients' headaches return soon after surgery. These people typically learn to live with their pain with the help of prescribed medications. (If you're a TMJ patient, don't worry; this book is for you, too.)
So why do I consider TMJ a 'trap' for chronic headache sufferers? Two things have always puzzled me about the TMJ theories. First, dentists see people with absolutely lousy looking teeth and really terrible bites all the time; but as a group, these people don't necessarily have more headaches than those people with perfect teeth. In fact, published literature shows that the teeth and the bite are not factors in predicting who will have headaches. Splint therapy can be expensive, and 75% of patients with severe headaches fail treatment, so something here just doesn't add up. Secondly, if a jaw joint can become damaged enough to cause a headache, treatment is directed at relieving the symptoms and repairing damage. Assuming therehad been no traumatic event, how could the joint become so damaged in the first place?
"Most of the "TMJ specialists" in town had worked on me one way or another. All of my teeth had been capped--twice. My jaw had been surgically broken and reset. I had been given three separate "splints" without success (I actually got worse). I was accused of being alcoholic and in need of professional counseling to rid me of my terrible headaches. I was put on "display" in front of a TMJ symposium at a local hospital so that an auditorium of doctors could try to figure me out...nobody could. But now it seems so simple! One month after treatment with Dr. Boyd, I'm a new man!" Dene Davidson, San Diego, CA