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What is TMJ Pain?

It can be hard to know what something means in the medical world because they use abbreviations a lot of the time. TMJ stands for temporomandibular joint which is anything related to the components that make up and participate in the maintenance and movement of that joint or jaw. Anything that can go wrong with those structures can be labeled as TMJ disorder or TMD, and TMJ pain is usually a hallmark finding. The origins, classifications and treatment of TMJ pain can be broad and complex. The focus of this article will be in the form of answers to questions about jaw pain. What makes up the jaw? What causes jaw pain? Can jaw pain cause tooth pain? Can jaw pain cause neck pain? Will jaw pain go away? Before moving forward with answering these questions, an understanding of the main jaw structures and its function is needed. Each structure has certain characteristics and functions that have defined pain patterns and a good understanding of them will make answering these questions simple and easy to understand.

What makes up the jaw?

For the purpose of this article let’s define what makes the TMJ aka “jaw” up into two types of tissue: hard tissue (bone and cartilage) and soft tissue (muscles & tendons). There are other soft tissues that have an important relationship to the jaw, however the ones mentioned here are sufficient to provide some answers to our questions. 

THE BONES

It could be argued that one of the main bones of the jaw is the “jaw bone” or in medical terms the mandible. As shown in the posted image, it kind of has a “J” shape to it making the word “jaw” even more appropriate. It is the bone that probably has the most moving component involved in the functional aspect of jaw mechanics.

THE MUSCLES

Any muscle that connects to the mandible has a part to play in the jaw which could also be said that whatever bone that has a connecting point that connects directly to the mandible could also be considered part of the jaw. The following diagram shows all the bones and muscles that connect to the mandible (platysma, superior pharyngeal constrictor, deep masseter, superficial masseter, lateral pterygoid, hyoglossus, styloglossus, genioglossus, mylohyoid, medial pteryogoid, bucinator, depressor anguli oris/inferioris, mentalis, temporalis, and superior longitudinal lingual)

In simplest terms any abnormal condition taking place in these structures and their moving patterns can contribute to symptoms felt in and around the TMJ area. It could be a recent trauma to the jaw, osteoarthritis build up, congenital malformation of the jaw and cranium, etc.  One particular condition that is often overlooked, but has a larger participating role in jaw pain and pain in general is myofascial pain or trigger point pain. 

What causes Jaw Pain?

Trigger point origins came from John Kellgren, a physician and professor of rheumatology at Manchester University in the early 19, who observed that the pain in myalgia or what is known today as myofascial pain syndrome; originates in small circumscribed, tender points in muscles. He noted that depending on the depth and intensity of pressure, pain could be felt at the pressure point or radiate or be felt at different locations in the body. He also observed that these pain patterns with/without pain referral could be alleviated with injections of pain killer (novacaine) medication at these points.
 Kellgren’s work inspired another doctor Janet Travell to study it further. She discovered that these “tender” points were triggered by hyperactivity at these points in the muscles which can cause the muscle to change at those points into a more fibrous or more “hardened” area. She gave them the name trigger points (TrPs). Her work along with others, led to mapping a majority of the body’s muscles trigger point areas and their pain referral patterns. Their findings are well documented and discussed in their extensive book Travell, Simmons & Simons’ Myofascial Pain and Dysfunction where the process of TrPs formation can be studied more in depth. For the intent of this article it can be summed up as an over increased amount of effort/strain/prolonged contraction or over contraction in a muscle fiber which results in the formation or activation of a trigger point(s). Basically it can be streamlined into an “overworked” muscle and when it is overworked it complains via pain. A similar comparison could be made to overworked individuals as well–they are prone to complain. 

For the purpose of this article, trigger points of muscles that have a direct relationship to jaw motion and or attachment to the jaw; and structures that do not have direct connection to the jaw, but have trigger points that refer pain to the jaw area will be highlighted. 

One might ask, what causes this over increased amount of effort/strain/prolonged contraction/ overworked behavior in a muscle? This is a challenging question to answer because there is no quantifiable test that can be done to label a muscle of having a trigger point because of xyz.  It takes skilled hands, good functional history, knowledge of muscle function and anatomy and experience to properly identify them and treat them. 

So with regards to the jaw pain, there could be many causes due to the fact that there is 18 different muscles, as listed above, with connections to the jaw let alone take into account other muscles not connected to the mandible that refer pain in and around the TMJ area!  

However with just considering the muscles of the jaw and their trigger point activity and patterns, sufficient answers to the questions stated above should be attainable albeit not all inclusive. 

Can jaw pain cause tooth pain?

One culprit of causing tooth pain is the masseter (superficial and deep)muscles. 

Trigger points or overworked areas of the masseter can refer pain to the top and bottom molar areas of the teeth.   The following image shows the referral pattern of the masseters trigger points.  The strong darker red color represents main pain referral sights of its trigger points while the lighter red color represents “spill over” pain from trigger points.  Information used to construct the image is found in the latest version of Travell, Simmons & Simons’ Myofascial Pain and Dysfunction.

The image shows that the upper and low molars can have referred pain from overworked areas of the masseter.  As most humans will testify that they do not like pain and will do anything to get rid of or avoid it; learning what to do and or not do to prevent the masseter from overworking would probably be of interest. 

Some examples of things to lookout for and avoid are: clenching or bruxing the teeth, gum chewing, nail biting, prolonged holding of the jaw on the mouthpiece of a pipe or cigarette holder.1 Others also could include prolonged overstretching of jaw in dental procedures, or being force to keep jaw in a closed position for extended periods of time like from wiring of the jaw shut due to a mandibular fracture. 

There also is some evidence to show that having an increasing strain/tension on the suprahyoid and infrahyoid muscles from activities causing forward head posture (monitor being too far away from the head, excessive downward looking at cell phones, prolonged desk sitting without breaks) or whiplash injury from a car accident can cause an increased pull downward on the mandible. This increased pull can create added extra effort for the mandible when closing the mouth and keeping it closed thus fatiguing the muscle out.1  

Anything that causes the jaw to adapt to a prolonged position for several hours at a time can cause constrictures within the muscle tissue further limited muscle ROM making it more prone to fatigue such as in mouth breathing especially when sleeping with a device like a CPAP machine which can also encourage a forward head posture further increasing strain on mandible.

Mentals stress is also a significant contributing factor. Schwartz et al2 and Auerbach et al3 observed the contribution of emotional stress to the development of active TrPs and pain in patients with TMD. The masseter muscles are among the first to contract in persons who are in a state of extreme emotional tension, intense determination, or desperation, and they often remain contracted for abnormally long periods of time. It is like clenching your teeth when times get tense and if the time is prolonged, repeated clenching continues. 
Other researches showed that people who engage in nocturnal bruxism have higher levels of salivary cortisol and perceived psychological stress,4 which again supports the idea that stress can contribute to the development of TrPs via excessive activation of the masseter muscle with bruxing.1 Maintaining good daily routine of an effective stress reliever can greatly help relieve jaw pain.

Can jaw pain cause neck pain?

The answer to this question is yes and maybe no. It comes down to the conundrum of which came first the chicken or the egg?  If someone developed jaw pain from bruxism due stress that same stress can also cause trigger points to develop in the neck muscle like SCM or trapezius (see image for muscle location). It could be said that procedures helping mouth breathing, which is having the jaw in a prolonged position in and of itself;  like a CPAP machine have been known to alter head position over prolonged usage causing strain on cervical muscles leading to neck pain. Or it could be someone getting an extended dental procedure for a jaw issue involving pain causing the head and neck to be in prolonged position causing contractures in neck muscles that lead to Trigger points that are felt in the neck-thus jaw pain leading to neck pain.

However, the reversal can also be said that prolonged mental stress caused an increase in trapezius and other neck muscle activity due to tensing which led to developing trigger points in neck muscles that then refer pain to the jaw. 
The following diagram shows how this is possible. The blue tones represent trigger points from the trapezius and sternocleidomastoids-aka neck muscles. The red tones represent trigger points masseter muscles.  Other muscles stated above also have trigger point patterns to the jaw head and neck areas. Refer to Travell, Simmons & Simons’ Myofascial Pain and Dysfunction for more details.5

Will jaw pain go away?

Needless to say that trigger point activity in jaw and neck muscles can cause TMJ related pain. Someone suffering from this may ask, “will this jaw pain ever go away?” The answer is a resounding yes this pain can go away. However, it depends on a couple of things.  

Taking the chewing gum activity mentioned above.  It can lead to overworked jaw muscles that can lead to trigger point, but how much of it can?  One individual may chew gum for years and not experience symptoms while someone who just picked it up gets jaw pain after one week! The answer has to be more than just stopping chewing gum. 

Normally any new activity that an individuals chosen to do requires the body to adapt to accommodate that strain of that activity. There may be some added pain during this time. This adaptation usually takes place, depending on the degree of intensity, 2-4 days after the activity in which the body then is ready for some more. 

 However, if there is an imbalance in the sequence in which the body performs the activity which causes a muscle or muscle group to overwork, trigger points develop. This can change the structure of the tissue depending on how long the imbalance has been going on to the point that the muscle is tough and more hard.  At this point Just merely stopping chewing gum does not eliminate the pain because the adapted change in the muscle is still there. Any use of the jaw, speaking, chewing food, etc while it retains these trigger points will continue to be irritating to that overworked muscle causing continued pain albeit maybe less intense. 

If an individual has reached this point, they would need to have professional intervention. A provider who is skilled in not only reducing the trigger point tissue, but also in the re-education of the muscle to joint position and moving pattern to a more balanced one. This would provide an environment where the potential for complete recovery is the greatest.  Recovered state that involves the individual getting back to chewing gum without the fear of overworking their jaw tissues because they know how to keep their jaw motion mechanics balanced.   

Conclusion

TMJ pain origins have many different factors that can contribute to it. One that is often overlooked is myofascial or trigger point cause of TMJ pain. Trigger points develop when a muscle is overstrained or put into a pattern that it gets overworked which changes its structure and causes pain. Pain that can be felt in the jaw and in other places like the teeth, and or neck. Merely just quitting the activity that caused the trigger point to develop may not be enough to eliminate the pain. The trigger point muscle(s) need to heal or regress back into their pre-overworked condition along with the body’s nervous system needs to be retrained on how to utilize the structures of jaw motion in a more balanced pattern. 

Usually a person would need to go to a couple of different professionals to get all of this done.  Maybe a physical therapist for the re-education part. A massage therapist and or acupuncturist healing of trigger points, and then a chiropractor to make sure the joints involved are centered so as to provide optimal mechanical advantage. 

We here at Integrated Health Solutions are equipped, educated and experienced in providing all four of these services under one roof!  We take the time each and every visit with our patients reducing trigger points with soft tissue release and medical acupuncture. We centrate the joint surfaces of the jaw and related joints via use of safe and gentle chiropractic adjustments.  We spend a lot of time helping our patients re-educate their nervous system so that they can activate the correct muscles in the right sequence to balance out the strain of the jaw or related activity.  This empowers our patients with the ability to maintain their results while getting back confidence to get back into chewing gum or other activities they couldn’t do before. Learn more about us by visiting our website www.ihsindy.com

Content provided by Dr. Andrew Sanders

References

1Donnelly, Joseph. Travell, Simons & Simons’ Myofascial Pain and Dysfunction (p. 105-110). Wolters Kluwer Health. Kindle Edition. 

2La Touche R, Paris-Alemany A, von Piekartz H, Mannheimer JS, Fernandez-Carnero J, Rocabado M. The influence of cranio-cervical posture on maximal mouth opening and pressure pain threshold in patients with myofascial temporomandibular pain disorders. Clin J Pain. 2011;27(1):48–55.

3Auerbach SM, Laskin DM, Frantsve LM, Orr T. Depression, pain, exposure to stressful life events, and long-term outcomes in temporomandibular disorder patients. J Oral Maxillofac Surg. 2001;59(6):628–633; discussion 634.

4Karakoulaki S, Tortopidis D, Andreadis D, Koidis P. Relationship between sleep bruxism and stress determined by saliva biomarkers. Int J Prosthodont. 2015;28(5):467–474.

5Donnelly, Joseph. Travell, Simons & Simons’ Myofascial Pain and Dysfunction (p. xvii). Wolters Kluwer Health. Kindle Edition.

Questions on how we can help? Call us for an exam and consult today! P: 317-449-2020
E: amie@ihsindy.com

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