You and Your Temporomandibular Joint (TMJ)

Around 12% of the population experience temporomandibular joint dysfunction (Known as TMD). That's a fair number of people! 

You probably don't think much about the mechanics of opening and closing your jaw too often. You just open and then you close it. The end. However, we move it all day long! We need to engage these chewing muscles (AKA muscles of mastication) to bite, chew and swallow! The muscles of mastication support the TMJ (and are often part of the dysfunctional picture) 

When problems arise with the temporomandibular joint, you may notice its difficult to eat and talk! 

                         
How does the TMJ work? 

The TMJ is the articulating surfaces of the mandible and temporal bones. It is designed to withstand large and repeated stresses to the joint surface and repair itself. Between the bones is a fibrocartilaginous disc. When patients experience clicking in their jaw during opening and closing, often it's the disc being displaced. The joint is also made up of a joint capsule and 3 ligaments that all provide stability to the area. Muscles of mastication move the jaw down and up (open and closed) as well as side to side and front to back. 

Before we begin diving into possible causes of TMJ dysfunction, first reference Temporomandibular Joint Dysfunction: Do's and Don'ts .

Can you get arthritis in the TMJ? 

Of course - almost every joint in the body can experience arthritis!  As of yet, there isn't a treatment that reverses arthritis. With that said, its important to recognize that pain has multiple factors.  Although arthritis may be one of the causes, other systems around the joint (nerves and muscles, for example) may also be contributing to your pain.  Managing these systems may reduce pain to a much lower level.  Your physical therapist can help you determine whether or not muscles and nerves are contributing to your pain and discuss and implement ways to treat it.  Take a look at our blog titled Jaw Pain And Physical Therapy for more information.

How many muscles do we have? 

We have 4 main muscles that act on the temporomandibular joint (the muscles of mastication):

• Masseter: its function is to close the mouth (elevate the mandible)
• Temporalis: it's role is to close the mouth and slide the jaw backwards
• Medial Pterygoid: assists in mouth closing, and individually deviates the jaw to the opposite side
• Lateral Pterygoid: has a large effect on the joint (it does so many actions!) It plays a large role in stabilizing the joint, as well as controlling movements of the disc. Additionally, it opens the jaw, protrudes (pushes forward) the mandible, and moves the jaw to the opposite side. 
  
  Other muscles we consider include:
• Muscles above and below the hyoid bone
• Deep stabilizers of the neck 
• Muscles underneath the head
  
  
  

  Trigeminal Neuralgia

  These muscles are innervated (controlled) by the mandibular branch of the Trigeminal Nerve.
  
  Some patients who have jaw pain may not truly have a dysfunction with the TMJ but instead something called Trigeminal Neuralgia. Trigeminal Neuralgia is irritation of the nerve caused by compression usually from a blood vessel as it leaves the brain. The symptoms of TMJ dysfunction and trigeminal neuralgia overlap but there are some that are clearly definitive of one or the other.  For more details on trigeminal neuralgia, refer to our blog titled,  Trigeminal Neuralgia or TMJ Disorder? 

Snap crackle pop!

Jaw clicking is related only to TMD, an irritated nerve can't click! Sudden, electrical shock like symptoms in the face are related to trigeminal neuralgia, not TMD. The third option, which is why a detailed history is important, is that there is actually both diagnoses going on unfortunately. They are not mutually exclusive. 

When the muscles of mastication become tight, they can tension the jaw in different directions as well as pull on that fibrocartilaginous disc. If the lateral pterygoid becomes tight, then clicking is much more common because the disc is being displaced. For more information on jaw clicking, refer to our blog TMJ Dysfunction: Why Does My Jaw Click?

However, not all jaw clicking is a problem! If you have clicking but no pain, it's typically not anything to be concerned about. Especially if it's a delayed or later click in jaw opening/closing. If you have extra mobility (hypermobility) throughout your body, you can have the same in your muscles of mastication. Making it easier for the disc to becoming displaced. 

Small jaw noises (not as considerable as a click) are common in 50% of the healthy population (sans pain). 

Rule of 3s (fingers that is)

You need to be able to open your jaw about 3 finger widths in order to be functional. That's how far you need to be able to open the jaw to eat and talk, at least. When the jaw locks or pain prevents you from opening wider it's time to be seen by a physical therapist. Excessive opening is a problem as well and can cause muscle imbalances. 

Physical therapists  help with tight muscles be releasing them with various manual techniques! We can even perform dry needling to these muscles. This should provide pretty immediate relief in the jaw pain and clicking/locking. For example, pain near the ear is typically related to the medial pterygoid muscle, especially if the ear structures themselves check out healthy. 

Additionally mobilizations to the joint to help it close or open evenly. The mandible needs to move laterally, inferiorly and anteriorly to open. Conversely, it needs to move posteriorly, superiorly and medially to close the jaw. Both of our TMJ joints might not be moving together in those directions when we open/close. That's where those joint mobilizations come in. Uniform opening and closing is very important for the overall function of the jaw. We would expect you be able to open the jaw further as well, to make eating and talking easier. 

Botox, not just for fine lines!

Some patients who respond well to dry needling to the muscles of mastication but the relief is short lived may benefit from botox injections. Your physician is the person who will ultimately decide if you are appropriate for botox injections. The botox (which is the botulism toxin) is a neurotoxin which forces the muscles to relax, and stay that way.  To read more about ways that botox can help with TMJ dysfunction, refer to our follow up blog Botox for TMJ.

You may find you also get neck pain, headaches, and ear pain with your TMJ pain. These are common and can be related or as because of separate musculoskeletal issues. A detailed history will help your physical therapist pin point what exactly is causing you pain. It also makes sure that they can actually treat you and your ear pain isn't related to an ear infection for example. 

How does sleep affect my jaw? 

Sleep strategies and posture adjustment are as important to treating TMJ pain as it is for someone who just has headaches and neck pain. Small changes can have a big impact. Sleeping on your back is the best position for TMJ pain where as sleeping on your belly is the worst. It rotates the neck and you end up spending extended time with pressure to the joint.

Keeping your face parallel to the ceiling and your ears in line with your shoulders is a good rule of thumb. You don't want the head pushed forward (along with he shoulders) because you have too much pillow. The pillow should stay just under the head and neck. 

Heat feels so good

One thing you can do at home to help manage your symptoms is heat! Heat increases blood flow, which brings more oxygen to your tissues, decrease tension and tenderness to muscles. It feels fantastic truly. You can use a heating pad just monitor closely for skin response to heat and keep it on for 10-15 minutes. Another option is a washcloth in the shower, held on your jaw. That can be combined with some gentle self manual massage that your therapist will instruct you in. 

What foods can I eat with TMJ pain?

You may have already started to do this next step yourself, but limit the texture of the food you're eating. Meaning, less crunchy/chewy and hard food, more soft foods. Now is the time to pull out the mashed potatoes and soup so those muscles can get a rest! Your jaw doesn't need to open as wide or work as hard to mash the food up small enough to swallow. 

Stop chewing gum!

This probably seems obvious, but don't chew gum! This is like constantly doing bicep curls all day long. Do you need to be able to contract your bicep and use your arm? Absolutely. But do you need to do it all day long? No, not at all. Our jaw muscles have a purpose in which to help us eat, talk etc. But needlessly chewing because we are bored? Nope. Just stop now. 

Resting position of the jaw

Don't clench that jaw! We all have stress right? Especially these days. Clenching the jaw makes jaw pain that much worse. Instead keep the tip of your tongue resting lightly on the roof of your mouth, with the mouth closed and breathe through the nose. That is the resting position of the jaw!

Relatedly, if you are always so congested that you have to mouth breathe, check in with your doctor to see what's going on. Open mouth breathing (at rest, not related to exercise) can aggravate the muscles of mastication. This is super common with mask wearing (refer to our blog Mask Wearing and TMJ Pain)! But you can breathe through your nose while in the mask, you will get enough oxygen.  Moral of the story? Don't forget the resting position of the jaw! 

Your physical therapist will help guide you in exercises that promote good posture and jaw positioning, especially after starting to release the muscles of mastication and improve joint mobility. We open and close the jaw so frequently throughout the day. Think about how often you move it in a single conversation. Wow right? SO MUCH. And that's just one conversation. That's a lot of repeated poor movement patterns over the course of one day. Time to retrain the jaw. 

Can you exercise your jaw?

You bet you can! There are a series of six exercises that are commonly used among patients with TMJ dysfunction. Your physical therapist will instruct you how to perform them and how frequently you should do them at home. Staying compliant with your home exercise program is key in maintaining the progress you make in the clinic.

These exercises focus on the following: 

• Tongue rest position with nasal breathing
• Controlled opening
• Rhythmic stabilization 
• Cervical Flexion
• Cervical Extension
• Shoulder Retraction (pulling the shoulder blades backwards)

Do I need a bite guard? 

The TMJ is a  joint that is often overlooked or not treated out fully. Specifically the lateral pterygoid. Many physical therapists focus on just the masseter muscle, but there is SO much more to the joint than just the masseter. Joint mobilizations and exploring the tension of ALL four muscles of mastication are often needed to make a substantial change in the tissues. Then supporting the muscles through exercise and behavior changes. 

What if I tried jaw surgery but have pain afterwards?

This can sometimes happen, as the muscles of the jaw and the joint may have been irritated or altered, depending on the type of surgery you had.  To learn more, refer to our blog Jaw Pain After Surgery.

Physical therapists treating TMJ in Columbia, Maryland

If you are suffering from jaw pain and are ready to do something about it, contact our office today! Our physical therapist specialize in TMJ dysfunction and can help you accomplish your goals!