Ask Dr. Gary: TMJ treatment can be complex

I have had jaw pain and clicking for a long time, which my doctor diagnosed as TMJ syndrome. I've tried medications, but they don't help for very long. And I don't really like the idea of taking medications long term.

I was wondering if other treatments like injections, steroids, or chondroitin work for TMJ pain. I work as a telephonist and talk for a living, and the pain is getting to be more than an annoyance. - S

 

Temporomandibular joint syndrome refers to pain arising from the temporomandibular joint of our jaw. The pain can radiate from the jaw to the ear or cheek, and even cause headaches.

The TMJ is a complex joint that allows our jaw to hinge open, shift side-to-side, or slide forward and back. It is hypermobile, attached by layers of thin connective tissues and muscles, and yet it's super strong, capable of translating about 150 pounds of bite force.

It performs the delicate movements of speech, and the repetitive motions of a lifetime's worth of chewing make it prone to injury.

Like any joint, it is as strong as the bones, soft cartilage discs, muscles and ligaments that comprise it. These tissues can become worn out or diseased, or just injured with the repetitive stress of chewing, teeth-grinding or dental malalignment.

Around a quarter of the population will have significant TMJ pain in their lives. Far fewer will have a true TMJ pain syndrome, but even among those, improvement is common, if slow. Eighty-five per cent become pain free within three years, according to one source I read.

As with all difficult-to-manage chronic pain conditions, everybody's got a cure, but none really stand up that well to scrutiny.

Doctors sometimes inject steroids, potent anti-inflammatories that can relieve pain but carry the unfortunate side-effect of weakening tissues with repeated use.

Chondroitin was well studied in arthritic knees in the $12 million GAIT trial in 2008, and found to be all but useless.

Glucosamine showed highly variable results in osteoarthritis trials, with the better studies concluding it was of limited value.

TMJ-specific studies are very few in number and usually enroll very small numbers of subjects, meaning they're limited in their ability to telling us anything meaningful but big enough to get the manufacturers a marketing blurb.

Some basic principles that seem logical in managing TMJ:

Be sure one actually has TMJ: dental disease, middle ear conditions, and trigeminal nerve disease can all masquerade as TMJ syndrome.

See your dentist and GP for an evaluation.

They can also identify the minority of cases in which there is a clear cause such as rheumatoid arthritis or gout, or a physical breakdown of the joint or disc caused by trauma or malalignment.

Medications, dental splints or even surgery can be corrective in some cases.

For the remainder, which are most cases, treatments exist to alleviate bruxism (grinding) and clenching such as dental plates, tricyclic antidepressants, sedatives, counselling, biofeedback and other anti-anxiety methods.

Anti-inflammatories and massage are reasonable starting points in most cases.

Beyond these lie specialised treatments like TMJ washouts using solutions injected into the joint space, arthroscopic joint surgeries, and even botox injections.

At that point, one would hopefully be under the care of a knowledgeable ENT doctor who can co-ordinate a team-based approach to symptom management.

As you can see, treatment of TMJ syndrome can be complex.