This case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.
The patient can be young or old, male or female. The patient could even be you.
Doctor: Good morning. How are you today?
Patient: I’ve been better.
Doctor: How can I help you today?
Patient: I am having horrible problems with pain in my ear.
Doctor: How long have you had this problem?
Patient: I have had this off and on for the past two years.
Doctor: Have you seen a doctor about this problem?
Patient: I have gone to my primary care physician and, on occasion, to urgent care or an emergency room. Some doctors have diagnosed it as an external ear infection, which they treated with ear drops. Some doctors have diagnosed it as a middle ear infection, which they treated with antibiotics. Others, not being certain which it was, have treated it with both ear drops and antibiotics.
Doctor: Have these treatments provided improvement?
Patient: It doesn’t appear that the ear drops or the antibiotics make much difference. Fortunately, many of the doctors provided me with pain killers, and these seem to provide relief.
Doctor: Can you show me exactly where it hurts?
Patient points to an area in front of the ear.
Doctor: You seem to be pointing to an area in front of your ear rather than on the ear itself. Is that correct?
Patient: Yes.
Doctor: Does the pain ever extend onto your face?
Patient: Yes, it will sometimes spread down along my jaw. I can sometimes feel it behind the ear, and when it’s really bad, I will feel the pain up in my temple region, here in my scalp.
Doctor: Is it worse when you chew?
Patient: Absolutely.
Doctor: Do you grind your teeth at night, a condition we call bruxism?
Patient: My husband and dentist say I do, but I don’t know if I do.
Doctor: Do you ever clench your teeth, particularly when you’re stressed?
Patient: That I do, and it sometimes causes pain.
Doctor: Do you chew gum?
Patient: Always.
Doctor: Do you have any other serious medical problems, particularly problems involving arthritis, joints, or other muscles?
Patient: No.
Doctor: Let me then take a look at you.
Patient: Fine.
Doctor then performs an examination. This involves a complete ear, nose, and throat examination. Hearing is normal, examination of the ear is normal, the patient’s jaw joint, called the temporal mandibular joint, is exquisitely tender to the doctor’s pressure over the joints, and the patient winces when asked to open and close their mouth as pressure is applied here. Examination of the mouth shows normal teeth; however, several molar teeth are missing on one side.
Doctor: Based on your history and physical examination, you have a condition which is called temporal mandibular joint disease, abbreviated TMJ.
Patient: What causes this?
Doctor: Basically, the jaw joint is a very sensitive joint, and when one puts undue stress on it, either by grinding one’s teeth, clenching, or just using it excessively (i.e. constant gum chewing), the joint muscles can be thrown into spasm. The spasm causes pain. Pain causes spasm of the muscles, and then a vicious cycle ensues with pain, spasm, pain, spasm, etc. This cycle unfortunately becomes difficult to break.
Patient: Do my missing teeth play a role in this?
Doctor: Yes, they do. You are missing several molar teeth on one side. This means that even when your jaw is at rest, it sits in a position that is slightly askew to where it is supposed to rest. This puts stress on the joint. This also causes spasm, pain, and TMJ.
Patient: Is there anything else that can contribute to this problem?
Doctor: Are you under much stress?
Patient: What exactly do you mean by stress?
Doctor: Is work stressful? Do you have problems at home, problems with your parents, or problems with your loved ones?
Patient: Well, I do have a stressful job. That horrible boss, nothing makes him happy. All of us have to work 10 hour days, and it’s just a stressful environment. Unfortunately, I need the money and have not been able to easily find other employment.
Doctor: How do you deal with the stress?
Patient: I don’t deal with it. I come home, take care of my kids, cook dinner, clean the house, do laundry, go to bed, get up the next morning, get everyone off to work and school, and then go to work myself.
Doctor: Do you ever have time for yourself?
Patient: No.
Doctor: Do you exercise?
Patient: I would like to, but I don’t have time.
Doctor: Let’s accept that your problem is TMJ. It’s not your ears. Ear drops and antibiotics are not going to do you much good. We need to treat the primary problem.
Step 1: You need to put the joint at rest. This involves a soft diet and no more gum chewing.
Step 2: Non-steroidal anti-inflammatory agents should be taken. Motrin is an excellent non-steroidal, and 200 or 400 mg twice a day should be taken on a regular basis. If you have stomach problems, take the Motrin with a little food or with Tums. If you still have problems, let me know.
Step 3: You can put hot or cold compresses on the side of your face next to the jaw joint where it hurts. Some people prefer hot, and some people prefer cold. The cold helps reduce acute pain and inflammation, and the hot helps stimulate healing. If the majority of your problems come from grinding your teeth at night, then a cold pack in the morning and a hot pack at night should work well.
Patient: How long should I leave the packs against my TMJ?
Doctor: 15 or 20 minutes is ideal, but even as little as 5 or 10 minutes, particularly if they provide you some relief, is helpful.
Patient: What next?
Doctor: I would like to get a CT scan of your jaw joints. This is to make certain that you don’t have arthritis or a tumor.
Patient: I have a friend who has TMJ, and she got an MRI.
Doctor: There are many who believe an MRI is useful in evaluating TMJ. I have not found this to be true, and at least for our initial evaluation, I prefer the CT scan.
Patient: What next?
Doctor: I would like you to begin physical therapy. We have a physical therapist who is particularly skilled in TMJ problems and will teach you how to properly move your mandible and how to begin to strengthen and relax some of the muscles of the jaw joint.
Patient: That sounds like a pretty busy schedule.
Doctor: It may be, and there are 2 more things.
Patient: What are those?
Doctor: First, you need to see your dentist and see about restorative dentistry for the missing molars. I would like you to put your jaw back into balance, and restorative dentistry is the proper way to do this.
Patient: Will my medical insurance pay for this?
Doctor: Unfortunately not. However, it is something you need to get done if you want to treat the TMJ.
Patient: You mentioned one other thing. What is that?
Doctor: Stress reduction.
Patient: Meaning?
Doctor: You will never get rid of your TMJ as long as you’re under stress, clench your teeth at work, and grind your teeth at night. It may not be possible for you to find a less stressful job, but it is possible for you to treat your stress.
Patient: With my busy schedule, how would you recommend I do this?
Doctor: First, whatever your daytime schedule, you need to take an hour prior to bedtime that is set aside just for yourself. This is a time for you to unwind, get rid of the day’s stresses from your head, relax, and go to bed in a proper mindset.
Patient: I have too much work to do.
Doctor: That’s your choice, but if you continue with your current schedule, your TMJ will continue to haunt you.
Patient: Can’t you fix it?
Doctor: Not without your help, stress reduction included.
Patient: Anything else?
Doctor: Yes. I would like you to join a yoga class. This is a class away from the home. Yoga is a physical exercise that is a stress reducer, but it is also a mental exercise. Some meditation is necessary for you to learn how to relax. There are many meditation forms - - Buddhism, Daoism, and yoga. It doesn’t matter which meditation form you use, but for many new to this, yoga combines a physical exercise with a meditation exercise, and has been found to be useful.
Patient: I don’t know if I can do all that.
Doctor: Well, let’s start out simple. You work on the soft diet and use the cold or heat packs. We’ll get you the CT scan and get you to physical therapy. Begin to look into the yoga, exercise, and stress reduction. I’ll see you again in a month, and we will go from there.
Patient: It’s a lot to do.
Doctor: I know it is, but maybe the problem is that you’ve been doing too much. Take this as a wake up call to slow down a little bit and get your life into proper balance. Working together, maybe we can have this unwanted pain go away.
Patient: I hope so.
Doctor: I hope so, too.
Patient: Thank you.
Doctor: You’re welcome.
Additional Thoughts
There are many professionals from many specialties who profess expertise in the matter of TMJ. They each come with their own training, background, and experience. TMJ is a complex problem. It is intimately connected to one’s anatomy, stress levels, and psychology. One must undertake all recommendations and treatments with appropriate caution.
If the treatments recommended in the above consultation fail to provide benefit, and if there is no objective anatomic abnormality such as arthritis, tumor, or fracture, then additional ideas and treatments should be considered. First and foremost, if there is significant psychopathology contributing to stress, grinding and clenching of the teeth, and resultant chronic pain disorder, appropriate psychological evaluation and treatment become critically important. If an individual has somaticized his/her psychological difficulties, there is no treatment that can ever take away the pain. One’s psychopathology must be diagnosed and treated, and only then can the physical problems be successfully addressed.
TMJ is a chronic pain disorder. As such, it may benefit from neuropathic pain medication. I generally prescribe low-dose amitriptyline, and have found that 10, 20, or at most 25 mg often provides significant benefit. Amitriptyline causes some sleepiness, so it is typically taken prior to bed. Many practitioners believe that higher doses of amitriptyline and other chronic pain medications are appropriate; however, at higher dosages, these medications have side-effects and are not more efficacious, in my clinical experience. For the rare individual who is sleepy during the day, Nortriptyline can be substituted for amitriptyline. Nortriptyline causes some elevation of mood, and is therefore best taken in the morning.
For chronic muscle spasm, BOTOX® (Botulinum Toxin Type A) injections are also effective. These are expensive, and often are not covered by medical or dental insurance policies. The injections cannot be utilized repeatedly; with chronic use, they will weaken and ultimately paralyze the muscle. There is, however, the occasional patient in whom the TMJ disorder is prolonged, severe, and recalcitrant to treatment. For these patients, a brief series of BOTOX® injections will provide a break in the spasm and improvement in the symptoms.
The use of pain medications is always contentious. TMJ is a chronic condition, and if one elects to get started with pain medications, there begins to be talk about narcotics, addiction, and functioning. Once one gets started with a narcotic, whether it is a codeine product such as Vicodin or a morphine product, one becomes very quickly addicted to these medications, especially those with chronic pain. No doctor wants a patient to be in pain, but for the chronic pain patient who is started on narcotics, the doses will, of necessity, begin to alter mental alertness and capabilities. This is a very difficult decision to make and should be undertaken with a pain specialist. My general recommendation to patients with waxing and waning TMJ problems is to avoid narcotics and tranquilizers.
Finally is the issue of surgery. Numerous operations have been proposed and used in the treatment of TMJ. These include endoscopies, joint irrigations, joint injections, and endoscopic and open operations on the disk and the joint itself. These operations, unfortunately, have not been successful. There are surgeons who have anecdotal experience that they believe support their application; however, scientific validation does not exist. My recommendation is that such procedures be avoided.