How to Take the Bite Out of TMJ Jaw Pain with Karyn Kahn, DDS

Podcast Transcript

John Horton:

Hello, and welcome to another Health Essentials Podcast. I'm John Horton, your host.

Two of the most complex joints in your body exist in your head and connect your lower jaw to your skull. These joints, known as the tempera mandibular joints or TMJ for short, also can be quite a pain, as more than 10 million Americans can verify. Now, TMJ jaw aches often disappear as quickly and mysteriously as they arrive. The bad news is that hurting also may linger far longer than you want. Luckily, we've got dentist Karen Kahn on our contact list, and she has some tips you can try to end TMJ tenderness. She's one of the many experts at Cleveland Clinic who pop into our weekly podcast to offer advice to help you feel your best. So, let's learn some TMJ self-treatment strategies so you can talk, chew or even whistle without pain.

Welcome, Dr. Kahn. Thank you so much for taking a little time today to come chat with us.

Dr. Karen Kahn:

Thank you for having me.

John Horton:

Oh, love having, whenever anyone makes some time, it's always, it's great. We learn so much.

As I was researching this, I was amazed at just how common jaw pain is. I think I saw it was the second most common kind of achy joint other than your back. I mean, I take it that's something that's not a surprise to you.

Dr. Karen Kahn:

No, it isn't. Basically, it is the most common type of musculoskeletal pain, second to back pain. Approximately 33 percent of the population have at least one type of symptom of a temporal mandibular disorder. The question of prevalence becomes rather difficult because of the lack of consistency in defining what a temporal mandibular disorder means. It could be either a disorder of the two temporal mandibular joints, the muscles that move the jaw or the way the teeth come together, otherwise known as occlusion. It becomes very important to be able to determine the causes of a temporal mandibular disorder and then determine what is the proper diagnosis and what treatment is.

John Horton:

Well, this is perfect. This is our whole conversation we're going to get into. If you can give us a little background when you're looking at these TMJ disorders — what's happening in your jaw when the pain comes and what might be triggering that sort of condition?

Dr. Karen Kahn:

Sure. To answer your question, first, we have to understand basically how the jaw system works. We have two temporal mandibular joints that act as an analogy, like the closing of a door. The door closes with two solid stable joints and so does the jaw. The muscles then close the lower jaw against the upper jaw and the teeth should come in contact simultaneously with the joint closure.

John Horton:

We do that thousands of times a day. Right — I mean, when you're talking, when you're eating, I mean, your jaw is going up and down and that joint's moving.

Dr. Karen Kahn:

Exactly, but when we're talking, the teeth never really come in a ton of contact, and when we're chewing, we have food between the teeth, and so it becomes a problem when patients are overusing the system either by grinding or clenching their teeth during the day or at night.

John Horton:

That is a fabulous description. When you're starting to have these issues, when the problems do start to develop, what kind of symptoms do you have with a TMJ disorder?

Dr. Karen Kahn:

One of the most common symptoms of an overload to the temporal mandibular joint or the jaw system is a noise in the joint, and that could be a clicking, popping, a sandy sound like crepitus.

John Horton:

Do you get that when you eat? I know, sometimes, I mean, I think we all get that where you chew, and you get that little pop right at the top.

Dr. Karen Kahn:

Yeah, and that's indicative of there's a little cartilaginous disk that separates the two bones in the joint, and this disk is tethered on the top of the disk in a normal situation, but due to some overload to the joint, a pull on the muscles, that disk can become displaced. When you open, you may hear a little click when you click back on the disk or a popping nature when you pop on and off the disk, and sometimes, the disk just becomes so thinned or worn out that you may hear a bone-to-bone sound, which is what we call crepitus.

John Horton:

Now, if you get that every once in a while, is that just kind of normal or, I mean, should you be a little concerned?

Dr. Karen Kahn:

Many people have a clicking or popping of their disk and it's asymptomatic, otherwise, there may not be any pain. There may not be any dysfunction with chewing or talking and they go through life with the disk being displaced. The problem becomes if there's constant overload because the disk acts as a pad between the two bones and if that is thinned or displaced, we get excessive pressure that can lead to certain things like osteoarthritic changes in the joint.

John Horton:

Now obviously, if you have jaw pain that would be assigned to you as a TMJ issue, but I know when I was researching ahead of our talk, it seems like you can also have pain in a lot of other areas that you might not think of.

Dr. Karen Kahn:

There are multiple types of pain that can come from a temporal mandibular disorder, and the first being the jaw pain, the temporal mandibular joint, which can be a rather sharp type of dull aching pain, too. Then, the muscle pain — again, that's from the muscles that move the jaw get overworked and they can be a dull, aching, constant pain. Then we can also see generalized tooth pain from parafunctional habits.

John Horton:

What about elsewhere in your body? I thought I had read that you could get headaches or earaches, even neck and shoulder pain.

Dr. Karen Kahn:

One of the most common disorders, part of temporal mandibular joint, is called myofascial pain. Myofascial pain is a musculoskeletal type of disorder where it is characterized by trigger points in a muscle. Now, these trigger points are taut bands in the muscle that can become active or quiet, and when they become active, that's when they begin to refer to different areas. The site of pain, which may be in your jaw muscle, may be referred to the ears. It can cause tinnitus — neck muscles can result in dizziness and pain that is not necessarily the source of pain. It becomes very, very critical that we try as dentists and as physicians to localize the source of the pain, the cause of the pain, before we begin to treat the site of pain.

John Horton:

It always amazes me how the body, you can have a pain point in one spot and that pain just kind of migrates someplace else. I guess it's kind of the magic of the way anatomy works.

Dr. Karen Kahn:

It gets very confusing. It does get very confusing. Dentists will do a thorough examination. They'll palpate muscles, they'll palpate the temporal mandibular joints, they'll do some testing to see if the joints are capable of taking loading before there's a complete diagnosis and a treatment plan set up.

John Horton:

Now, do you also get some clues that maybe there are people who are more prone to getting TMJ disorders?

Dr. Karen Kahn:

Yes. Patients who are prone to temporal mandibular disorders [TMD] may have a systemic overlay to their TMD. That could be in the form of rheumatoid arthritis, osteoarthritis, and women are also more susceptible to TMJ probably because of some hormone effects.

John Horton:

I think you had said that it was up to like 90 percent of the patients are usually women.

Dr. Karen Kahn:

I see that not only in the literature, but in my own private practice, and more research is being done regarding the effects of hormones on the temporal mandibular joints.

John Horton:

Well, that's really amazing. You rarely see something that's that startling, such a big gap.

Dr. Karen Kahn:

The other type of symptom or result of temporal mandibular disorder are patients who are on certain medications that can increase grinding and clenching — some of the SSRI medications, such as anti-anxiety medications, can increase grinding and clenching, which in turn, then overloads the joints and the muscles, leading to a temporal mandibular disorder. Stress in general, it uploads the autonomic nervous system. We have really no control over our muscles. We do have control of how we respond to stress. So, some of the modalities such as acupuncture or stress reduction therapy can help, too, to reduce the overload to the joints.

John Horton:

On this podcast, we talk all the time about the importance of self-care and taking care of yourself and slowing down. It's amazing how that covers so many different medical issues.

Dr. Karen Kahn:

Yeah.

John Horton:

Dr. Kahn, what kind of symptoms come with a TMJ disorder?

Dr. Karen Kahn:

I would think that to answer that the primary cause would be pain in the preauricular area, which is the temporal mandibular joints right in front of your ear. It will also be some dull aching pain and the sides of the face where the muscles are. From that, it has an effect by the myofascial pain, which could be characterized by trigger points in the muscles. Now, trigger points are taut bands in a muscle group, and what that can do is they can become active, or they can become quiet. When the trigger points are active, that's when they begin to refer to different areas. The site of pain can be different than the source of pain. When this occurs, there's a multitude of symptoms that are seemingly unrelated to the jaw or the TMJs, and this could be headaches, tension-type headaches. Myofascial trigger points can act as a trigger to migraines and, in fact, some of the muscles can affect a patient's tinnitus, which is ringing in the ears or buzzing in the ears.

That's because the neurology from the jaw and neck muscles have been shown that these nerves can stimulate the hearing centers in the brain. You could be in a quiet room with no sound available, but a patient is having the centers of the brain being stimulated by the nerves from the jaw and neck muscle. With that, some patients can actually change their tinnitus. We call that modulating with jaw clenching, jaw opening, neck turning.

This is a symptom, too, associated with a temporomandibular disorder. This was documented very well in a mild fascial trigger point book by Janet Travell. What can happen is that it’s confusing, is that we start to treat the site of pain without even understanding the true source of pain. Patients will have generalized tooth pain, and this is a result possibly of my fascial trigger points in their clenching muscles. They may not be able to open their mouth as well, and that could be from an intracapsular TMJ pain or disorder, but also from the muscles that open the jaw. It's very important to determine whether the source of pain is from the temporal mandibular joints, is it coming from the jaw muscles and the neck muscles or is it a bite problem? Oftentimes, it's a combination of all three.

John Horton:

It sounds like there's a lot of dental detective work that sometimes goes on if somebody comes in with these sorts of pains.

Dr. Karen Kahn:

That's exactly right, and I think that's why I enjoy my TMD patients so much.

John Horton:

Well, clearly from what you laid out there, the feeling that comes with a TMJ disorder is not something that you want hanging around. If you get some of these symptoms that you mentioned, as I understand it, there's a lot of things you can do that might be able to lessen that problem and take that pain away. Let's roll through some of them. I got a little list here and you can explain why it would help. I guess the first one would be to apply moist heat or cold packs. When should you do each and what will it do?

Dr. Karen Kahn:

That's a very good question. Either moist heat or cold. Well, cold has an effect of numbing. If you have a sharp, acute pain, I recommend a cold compress. Now, this is good if it is a sudden onset pain in the joints themselves indicating there might be an inflammatory process going on, the cold will help numbness and reduce swelling. If the pain persists for more than two or three days, I will consider using a moist heat compress. With chronic pain patients, their pain — due to overworking of the jaw joint and the jaw muscles — I would recommend moist heat compresses at least four times a day, and that along with massage of the sore area would be helpful.

John Horton:

OK, well we're off to a great start. Those are fabulous things to do. I also saw you should eat softer foods to avoid some intense chewing.

Dr. Karen Kahn:

Yes, we want to avoid all gum chewing because that uses a muscle that moves your jaw from side to side. Soft foods would help reduce the overload to the joint and decrease inflammation. We can also do some jaw stretching exercises, and this is a good one to do by putting your tongue at the roof of your mouth and stretching open for six seconds. Relaxing, do it again for six repetitions, and then do the exercise four to six times a day. That will help stretch some tight muscles that may also help relieve some of the contraction of the muscle.

John Horton:

I have to say I've done a lot of stretching over the years, but I have never thought to stretch my jaw muscles.

Dr. Karen Kahn:

We don't want to stretch our jaws so wide that we pull the joint too far open. By putting your tongue on the roof of your mouth and just opening it to when you feel it stuck and hold that, that will prevent you from opening so wide that you're displacing the condyles too far.

John Horton:

This seems to go right into the next one, which I read where good posture can help improve that jaw pain, which really surprised me. Tell me how does that kind of link in?

Dr. Karen Kahn:

Well, first of all, the teeth. I'd like to share that the teeth should only contact the upper and lower teeth should only contact when we swallow. If you try to open your mouth with your, if you try to, excuse me, swallow with your mouth open, you can't do it. That's the only time the teeth should actually touch. When I've been talking to you this whole time, my teeth never come in contact. When I chew food, I have a bolus of food between my teeth. I learned when to swallow when it feels comfortable, and my teeth come apart. It's patients who may be grinding or even resting their teeth together — that becomes a problem. We have to learn to keep our teeth apart during use. Lips together, teeth apart, and tongue resting somewhere on your palate comfortably. Like if you said the word … the letter N, that's where you feel your tongue should be.

John Horton:

Dr. Kahn, another point that I think I know we've talked about a little bit here, but you could also reduce stress, which will eliminate some of that clenching and grinding that can lead to that pain.

Dr. Karen Kahn:

Yes. Having some stress can increase the activity of the autonomic nervous system and it's referred to as an “autonomic response” because we really have no control over it. It's kind of like the fight or flight, but that can — response — but that can have an effect directly on the muscles of the jaw and the neck. We tighten up and so stress can increase the myofascial component of your temporal mandibular joint. Relaxation techniques are available by just listening to soft music, putting away your computer like an hour before bedtime. All these things will help bring down the autonomic nervous system. There are medications also that your physician can recommend, but there are certain medications referred to as SSRI medications that can actually increase grinding and clenching. We have to be careful of the type of medications we're prescribed and try to deal with our stress with relatively noninvasive types of procedures.

John Horton:

What kind of medications are those SSRI medications?

Dr. Karen Kahn:

They are, SSRI medications are anti-anxiety medications — selective serotonin reuptake inhibitors, SSRI. You might ask your doctor or your physician whether or not this might be contributing to some of your grinding and clenching, which then has an effect on muscle function and pain.

John Horton:

Can just plain aspirin and, like Advil®, ibuprofen, that people have around also be a good way to kind of reduce some of that pain?

Dr. Karen Kahn:

Ibuprofen and Tylenol® are good pain relievers. Ibuprofen is an anti-inflammatory, which can help, too, in temporal mandibular joint inflammation. A combination of ibuprofen and maybe 500 milligrams of Tylenol, if not contraindicated due to your medical condition. They're excellent medications to be used short term. I would say, though, if your pain continues on past two weeks, that's time to see a provider, either your dentist or your physician.

John Horton:

You had mentioned, too, earlier, massage, and is that as simple as just reaching up at where the joint is and just rubbing it a little bit?

Dr. Karen Kahn:

Massage is an excellent way to actually deprogram a myofascial trigger point massage and then followed by moist heat compresses. The other very successful modality is physical therapy. When we are grinding, clenching our teeth, or even with chronic pain patients, we have to undo what we're doing during the day. If we're clenching and contracting the muscles, we have to stretch those muscles. Physical therapies have different pain modalities. They can relieve what's called myofascial trigger point release modalities. They can provide deep heat, different types of tens units can be used to help reduce the pain in a muscle, but the most important, I think, is that they provide specific exercises that the patient can do on a daily basis to maintain comfortable neuromuscular harmony between their joints and their muscles.

John Horton:

All the working out that we do, I don't think many people spend a lot of time focusing on their jaws, so I guess maybe we need to pay a little more attention to it.

Dr. Karen Kahn:

We do overuse it too much, yeah.

John Horton:

Well, my wife would definitely tell you I overuse my jaw. One last thing, too, I saw where wearing a night guard might be able to help with that jaw pain. What does that do?

Dr. Karen Kahn:

Occlusal guards are appliances that are worn at night usually when we are unaware of clenching or grinding. That's called “parafunctional habits,” and studies have shown through functional MRI that grinding and clenching and any parafunctional habit comes from the central nervous system. We know that there's no way to really stop clenching and grinding. What we have to do is provide an occlusal guard that will not only protect the teeth from fracture, but it's designed — its proper design is to help reduce the amount of muscle contraction that can be generated. That, in turn, reduces the amount of overload to the temporal mandibular joints, allowing them to decrease the inflammatory process. There are other types of appliances that will hold the jaw in a particular position that may help in some early cases of disk displacement to recapture the disk. This you would have to talk with your dentist about it to see whether, and further imaging, to see the actual condition of the disk in the temporal mandibular joint before such types of appliances are undertaken. Splint therapy or grinding and clenching is a very, very effective way of reducing the amount of overload not only to the teeth, but to the muscles and to the joints.

John Horton:

These night guards, are these devices that you can just buy kind of over the counter at the store if you're having that, or do they have to be kind of prescribed and fitted?

Dr. Karen Kahn:

Yeah, over-the-counter appliances are generally soft, and it's not necessarily recommended for treatment of a temporal mandibular disorder. Just like we wouldn't want to put a filling in your mouth that isn't hitting properly, we don't want to advise you to put in a soft appliance that would be hitting some areas more than the other. This can upset the temporal mandibular joint. It can upset the muscle function. If you are experiencing a true temporal mandibular disorder with chronic pain, I would suggest that you have a dental professional fashion an occlusal guard that is functionally compatible with your joint position with the muscles and with the way the teeth come together when you're wearing the guard, the contacts on the appliance. Soft appliances cannot be adjusted properly to be able to provide neuromuscular harmony between joints, muscles and tooth contact.

John Horton:

If you do a lot of these self-help tips that you just suggested, like ditching the gum, reducing stress, maybe some massage, the heat, the cold, how often does that work to just kind of eliminate the pain and it goes away and you don't have anything to worry about?

Dr. Karen Kahn:

If, in fact, some of the self-help therapies like heat or cold applications, soft diet, practicing good head and neck posture, anti-inflammatories like ibuprofen and aspirin and naproxen, and you're still not getting relief, then I would recommend that you seek a consult with your dentist or physician.

Grinding and clenching at nighttime is something you can't control, so the dentist can help you with that to guard against any tooth pain and to help the muscles give up some of their contraction. You would also want to seek a consultation after a period of time, maybe six months to nine months.

If some of these self-help therapies are just not giving you relief, there may be another problem going on. This would be discussed with your physician, especially if it involves headache and migraines and dizziness — all these things — and the dentist will help direct you to the proper providers that may be able to come and give a little further, more information regarding a systemic issue.

John Horton:

Well, Dr. Kahn, you've given us a lot of options for dealing with jaw pain. Before we kind of say our goodbyes, anything else that you'd like to add?

Dr. Karen Kahn:

If you are experiencing a temporal mandibular disorder, don't ignore it because early on treatment, early on diagnosis, can help prevent this from becoming a chronic pain situation. Ask your dentist whether or not the clicking and popping that you're hearing or experiencing in the joint, what would it be caused by? Was it an acute accident that no longer exists, an episode like a trauma and is it just a result of the disk being displaced? Many patients can get along with a disk displacement if they're not having muscle pain, if they're not having joint pain. However, if it is a chronic condition such as grinding and clenching that can, without a disk in place, that can reduce, it can result in an overload to the joint leading to osteoarthritic changes. It's very important to catch these things early so that we don't develop into a problem that is chronic and leads to chronic pain.

Chronic pain is a lot different than acute pain because then it starts to affect our lives. It begins to affect our function and it begins to affect how the brain precedes input, nociceptive input, painful input into the brain, and so it might take less pain input to cause greater pain. That's why we don't want issues to become chronic. If you're experiencing some symptoms, talk with your dentist about it. Have them look to see if there is wear on your teeth and if you can see anything that can be addressed through physical therapy, for self-help therapy — all these things can help reduce the fact that it might become chronic. Every patient is different in their adaptive capacity to input into the brain. It's very important to have this conversation with a dental provider, whether it be your dentist, an oral surgeon, orthodontist — get some answers before the problem becomes chronic.

John Horton:

Dr. Kahn, thank you so much for that sort of expert advice and wisdom, and I think if anybody's got jaw pain, they know what to do now. Thank you.

Dr. Karen Kahn:

Thank you. Thank you for having me.

John Horton:

If you're experiencing jaw-related pain, know that you're not alone. It's a surprisingly common issue, and it's also one you might be able to eliminate on your own through some simple changes in your routine. It's worth a shot. Until next time, be well.

Speaker 4:

Thank you for listening to Health Essentials, brought to you by Cleveland Clinic and Cleveland Clinic Children's. To make sure you never miss an episode, subscribe wherever you get your podcasts or visit clevelandclinic.org/hepodcast. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.