Dentistry/chronic earache, non-infectious
QUESTION: Hello, Dr. Tieg. I am writing to ask if you have any thoughts on my situation. I have now had a chronic left earache for q8 months. I have been seen by my internist and an ENT MD, and nothing was found to be wrong. I have now been seeing a very talented physical therapist who has been doing trigger point therapy on various muscles in the jaw- masseter, SCM, pterygoid, etc, with some success, but the chronicity remains. The earaches are sporadic, and intermittent in severity and frequency. I consulted a dentist yesterday, who did a 3D tomography of the skull, other standard X-ray imaging and a thorough jaw.moth/teeth exam. He is sending the imaging to a radiologist specialist in Tx for further review, but, initially, his findings are that this is muscular (trigger point) and dental-related. I am not sure what this all means, but he showed me a flattening of the condyle in the left jaw, and a definite cyst. He said something about degenerative jaw joint on the left side. He wants me to wear a 24 hr/day splint, and have further jaw joint therapy with my PT. and who knows yet, what else will be involved in the tx. (I don't know if this adds anything to the mystery, but 30 yrs ago, I developed a high fever and had a herpetic virus , which resulted in what I call canker sores or whatever in my mouth, throat, gums. All cleared up over a few weeks, with no medications, etc. Since then, whenever I consume too much grain, esp corn, are stressed or lacking sleep or eating wrong, I get a recurrence of one )only one_ canker sore at the base of my left throat. Through these years, it used to always clear up as soon as I took some Lysine, but now, that doesn't seem to help much. In addition, last winter of 2012, I was ensconced in a knee brace and arm brace for 3 months due to a fall, was miserable, cold, very stressed, and the braces and restrictions came off that March, and March was when this earache started in full. I have been operating under my theory that that extremely stressful time may have caused me to unconsciously grit down and grind my teeth and if that was the cause of all this, then relaxation, the passage of time and this muscular work on my neck/jaw muscles causing referred pain to the ear would clear all this up. Now, I have this strange (to me) and somewhat frightening discovery of a cyst and a flattened condyle. The dentist who I consulted with does mot think that the March, 2012 onset had anything to do with all of my pain. I actually forgot to mention to him about the herpetic outbreak. Can you shed any light on what this all might mean? Thank you so very much for reading this.
ANSWER: Molly - I of course could not be sure what was occurring, but herpetic ulcerations and lesions are most likely not producing the pain. It does sound like muscular spasms are the cause of the pain. Most indicative of the muscles as the cause is the flattening of the condyle. That can occur from chronic spasms of the jaw muscles and a history of grinding.
The splint and PT is important, but the doctor who fabricated the splint and suggests the PT, needs to frequently checking for a balancing of your bite. One of the main causes of chronic episodes of spasms and grinding of the teeth is a lack of balance to your bite, or more specifically, the teeth when they bite down do not hit evenly. Curing that problem needs a relaxation of the muscles and repeated evaluation of the bite and how the teeth strike each other in chewing. Your dentist needs to be on top of this and may need to slightly adjust your bite a number of times to produce a balanced bite.
So do the PT and have the dentist examine you frequently.
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QUESTION: I thought that your answer was very insightful and extremely helpful and comforting. I wish to thank you very much, and tell you how grateful I am for the services that you are providing.
I did wish to ask you if you thought that the discovery of a cyst in that left jaw area was of much significance. I saw it myself on the 3d screen, and I am assuming that it is not a simple thing like a fluid-filled bubble that one can simply burst or remove, but, I suppose, it's more like a lesion.
It is noteworthy that you recommend a splint, as the PT does not agree with that modality for my situation, but the consulting dentist did. I guess that each practitioner has their particular views on that subject. I was hoping that I didn't need that, as it sounds miserable to have to have a splint in your mouth 24 hrs/day, except for easting. I know that you don't have a crystal ball, but is there some average time that patients wear those appliances before they don't have to do so anymore? In other words, if you stop wearing the splint, does your usual bite pattern (and pain) return? Also, when you were talking about having the dentist periodically check my bite, is that an ongoing, long-term issue? I have prided myself on only needing to see my dentist all these years for 2x a year teeth cleanings and general checkups, except for the usual cavities, etc. Does this mean now a whole lot of visits, with much frequency, to the dentist who creates my splint?
Is there a particular type of dentist, with certain expertise needed, that I should be looking for to follow me?
I value your free time, so please don't feel that you have to answer all these questions right away. You are indeed a very generous, kind man, and I am very thankful that you have taken all this time and energy to care about me and my situation. My very best regards.
Molly - Without viewing the xray of the cyst, it is a little difficult for me to comment on it.
A splint if used properly, not all day, but just at night during sleep, is a very helpful device that creates stabilization of the bite. Once stabilized, the jaw muscles are not always searching for the correct position of the teeth in a bite. Muscles and bites that are not completely stable, and searching, will create a pattern of the jaw muscles searching for a stable and relaxed position. That causes the muscles to be overworked and they frequently go into spasm. Just like a "Charlie horse" muscle spasm, where it is difficult to walk on the leg with the muscle spasm producing pain, the jaw muscles need a rest to reverse. Unfortunately, every time we swallow (that is done hundreds of times a day to swallow out saliva}, the jaw muscles close out teeth down to swallow. If the bite is not stable this will aggravate the situation hundreds of times a day. For that reason alone creating a stable bite with the guard is important to start relaxing the muscles.
So do what your dentist says, but don't wear the guard all day. Working with the PT is a good idea and truly knowledgeable PTs, and I have worked and used many of them, look at the appliance as a great help to their treatment, because the muscles start to relax.
Another simple help is to simply begin warm salt water rinses for about 5 minutes, 4-5 times a day. Concentrate the rinses towards the back of your mouth, on the sides against the jaw (where the muscles are attached)and it will go a long way in helping to relax the muscles. I wish you well and hope you feel better soon.