It’s TMJ Disorder

Why TMJ Disorder Gets Misdiagnosed as Migraines, Ear Infections, Tinnitus and Sinus Problems

Many patients who come to this practice for help have already seen someone else about the problem. Some have consulted an ENT for ear pain, tinnitus or sinus pain. Others have seen a neurologist for headaches, or a physical therapist for neck pain. They come to this practice because those workups did not find a clear cause, or because any treatment that followed did not help.

Occasionally it goes further. Pain from the temporalis tendon can feel exactly like a sinus problem, or exactly like an aching upper molar. It is convincing enough that sinus surgery is sometimes done, or a healthy tooth removed, before anyone considers the tendon. And of course, these decisions are never careless ones. The sinus imaging shows mild changes. The tooth looks healthy but hurts. The patient is in enough pain to push for something to be done. What is missing is not the examination itself. It is someone who can weigh the whole picture: how the symptoms fit together, which findings carry weight, and what they add up to. Without that, there is nothing to set against the imaging and the tooth, and so the procedures sometimes go ahead.

Patients are often surprised to find that TMJ disorder is not difficult to diagnose. In many cases it can be sorted out in a few minutes.

So What Is TMJ Disorder?

TMJ disorder covers a range of problems. The most common is nighttime clenching leading to pain and inflammation in the muscles, tendons and ligaments that move the jaw. The same clenching or grinding can overload the joint itself, causing inflammation and pain in front of the ear, and over time arthritic changes.

The majority of pain associated with TMJ disorder is muscular, not joint. The joint gets the name and the attention, but the muscles are usually where most of the pain is coming from.

Problems inside the joint are known as internal derangements. These are where popping, clicking and locking come from. Popping and clicking can come from more than one source, and effective treatment depends on knowing which.

Many patients have both muscle pain from clenching and a joint problem at the same time.

One thing worth understanding early. Classic TMJ disorder is best understood as nighttime clenching or grinding rather than by pain alone. Some people clench for years without symptoms. That can change. Contributing factors may increase at some point in life, or the joint itself may begin to break down after years of overloading. Either way, clenching that was once tolerated for decades can at some point lead to pain.

How to Understand Clenching

Patients often arrive at the office with their own theories about clenching or grinding. Some put it down to stress. Others are certain they do not clench at all, or simply do not know.

Whether someone clenches or grinds matters less than people think, because both actions overload the same muscles. If any of the chewing muscles are sore, the person is almost certainly clenching or grinding. As a general rule, TMJ disorder does not develop without one or the other.

The best way to understand clenching is this. For most people it is not a habit and it is not caused by stress. The brain is wired to do this during sleep. This activity is normal sleep for this person.

What varies is the threshold: how much clenching it takes before the muscles get sore. That is different for every person. Some people clench hard enough to wear their teeth down and never feel it. Others clench far less and are in pain, because their muscles reach that point sooner. Symptoms are not about how much someone clenches, but about how much that person’s muscles will tolerate.

Contributing factors such as stress, poor sleep or a disrupted airway can increase clenching in someone who already clenches during sleep. Contributing factors do not create clenching. People who do not clench during sleep do not become clenchers as a result of these factors. Treatment for TMJ disorder is about reducing the clenching enough that the muscles stop being sore.

Why the Diagnosis Gets Missed

Medical specialists are very good at what they do. The difficulty is that TMJ disorder produces symptoms that fall inside several different specialties at once.

Ear pain and tinnitus land with an ENT. Headache lands with a neurologist. Facial pressure lands in a sinus workup. Upper molar pain lands with a dentist. Each sees the one symptom inside their specialty, examines it thoroughly, and works it up properly. None of them have the luxury of evaluating the problem with a full understanding of TMJ disorders.

And so the accurate diagnosis can be missed.

If you think you have an ear infection and your doctor agrees, was your jaw joint checked to see if it was sore? If you have been diagnosed with migraines, was the temporalis muscle at the side of your head checked? And if the pain has been called sinus, was the temporalis tendon ever checked?

Often these checks are not done.

Migraine
Ear Pain
Sinus and Tooth Pain
Neck Pain

When a Symptom Might Not Be TMJ Disorder

Tinnitus is the clearest example of a symptom that could be TMJ disorder or could be something else. Ringing in the ears has several possible causes and even more theories. A medical workup for tinnitus will look for causes such as hearing loss or noise exposure, and where a cause is found it is usually treated. But often nothing is found, and treatment might go ahead on the most likely cause rather than a confirmed one.

That is reasonable. The question is which cause to work from.

When a patient has tinnitus and at the same time presents with findings consistent with TMJ disorder — tenderness in the chewing muscles, pain in the joint itself, soreness of the temporalis tendon, pain that worsens with chewing or opening, a jaw that locks from muscle spasm — then until proven otherwise the tinnitus should be considered part of the same problem. And since TMJ disorder is known to cause ringing in the ears, we do not go looking for another cause for the tinnitus before ruling out TMJ disorder.

The same reasoning applies elsewhere. A headache when the temporalis muscle is very sore. A sinus diagnosis when the temporalis tendon is severely tender. When findings consistent with TMJ disorder are present, those symptoms are part of the TMJ disorder until something proves otherwise.

TMJ Disorder and Migraine

Both cause pain around the temples, so they get confused.

If someone with migraines has a sore temporalis muscle, they probably also have TMJ disorder. In fact, studies show that 53 to 87 per cent of migraine sufferers have TMJ disorder.

Triggers. TMJ pain is provoked by chewing, talking, yawning and clenching. Migraine is more often triggered by light, sound, certain foods, hormonal changes or disrupted sleep, and chewing has little effect.

Pattern. Migraine comes in episodes lasting hours to days, often with nausea, sensitivity to light and sound, and a throbbing quality. Some patients also get an aura beforehand: visual disturbance, zigzag lines or blind spots. Jaw-related head pain is more constant, tracks with jaw use, and often means waking already sore from grinding overnight.

Migraine and TMJ disorder are sometimes associated in a condition known as mixed headache. A headache driven by TMJ disorder can be severe enough to trigger a migraine, and in those patients managing the jaw side often improves the migraines. That is worth knowing if you have been treating migraines for years without anyone asking what might be feeding them.

MJ Disorder, Ear Pain, Congestion and Pressure

The jaw joint sits directly in front of the ear canal, which is why a sore joint can feel exactly like an ear problem.

Fever, discharge from the ear and sudden hearing loss point to infection, and those need a medical doctor.

When those signs are absent and the jaw joint is tender, the ear pain is joint pain. Pain that worsens with chewing or opening wide points the same way.

Ear congestion and ear pressure are common complaints that can present as TMJ disorder, though the symptoms can have other causes. One question helps sort it out. Does the fullness ever clear, even briefly, the way an ear pops on a plane?

If it does, then for that moment the ear is working normally. Whatever is causing the fullness comes and goes, which points to something mechanical, usually tightness in the muscles around the eustachian tube. That is consistent with what TMJ disorder can cause.

If the ear congestion never clears, it falls into the same category as tinnitus. It could be several things. But when the other findings are consistent with TMJ disorder, the same reasoning applies: TMJ disorder is the most likely explanation until something proves otherwise.

TMJ Disorder, Sinus Pain and Tooth Pain

When someone has TMJ disorder, upper molar pain and sinus pain are more often coming from the temporalis tendon than from the tooth or the sinus itself. This is referred pain, and temporalis tendonitis is usually the cause. But when the TMJ disorder diagnosis is missed, the pain gets blamed on the tooth or the sinus.

The temporalis muscle runs down from the temple and attaches to the jaw bone in the mid face, close to the upper molars and not far from the sinuses. It is a difficult place to palpate, which is part of why it gets overlooked.

When the tendon is inflamed, the pain is felt in that area. It can feel like pressure across the cheek, or like upper molar pain. If the sinus imaging was clear or the tooth looks healthy on an X-ray, the tendon is the more likely source of the pain.

It works the other way too. A cracked tooth or an abscess can hurt in the same place, but it will not make the temporalis tendon or the jaw muscles sore. If those are clear, the problem is dental.

This is the misdiagnosis with the most permanent consequence, because a tooth that comes out does not go back in.

TMJ Disorder and Neck Pain

Neck pain and TMJ disorder often occur in the same patients, because the muscles that move the jaw connect down into the neck.

The relationship also tracks with severity. In one study, 59 per cent of patients with TMJ disorder had pain in the neck musculature, and both the severity and the distribution of that pain increased as the disorder became more severe. Patients without TMJ disorder had almost none. On palpation, between 23 and 67 per cent showed tenderness in the sternocleidomastoid, upper trapezius and other cervical and shoulder muscles, which was rare in people without the disorder.

This matters for how neck pain gets interpreted. It is tempting to treat tenderness in the trapezius and the back of the neck as evidence that the problem is postural rather than jaw-related. The literature does not support that. Tenderness in the upper trapezius and suboccipital muscles has been found to increase as the TMJ disorder becomes more severe, and cervical signs are better understood as perpetuating a TMJ disorder than as a separate cause.

So having neck pain does not argue against TMJ disorder. In severe cases it is expected. The muscles that move the jaw connect down into the neck, and the strap muscles at the front of the neck are used during clenching and chewing.

Posture and desk work cause genuine neck pain, and both problems can be present at once. But when someone has clear TMJ disorder findings and neck pain alongside them, the same reasoning applies as everywhere else. The neck pain does not need a separate explanation until the TMJ disorder has been treated.