Expert: Steven C. Scherr, D.D.S. - 12/23/2006

Question
Hey Dr. Scherr,

Sorry to send a question out to you at this time of the year.    Hope it finds you and yours doing well.

Ok, so here's the deal.  I'm a grinder, big time.  I always have been. As a child I tried 3 different bite guards and was never able to keep the device in all night.  I spit them out during sleep.

Anyway, I grind more with stress.  I'm a 3rd year medical student in the thick of a divorce.  The result is that I've been grinding a lot lately.

About a week ago I woke up with a lot of pain, stiffness, and popping in my right TMJ.  This was strange as it was the first time it had happened.  I figured the joint was just irrated and started taking some celebrex samples.  

The discomfort/dysfunction persisted, getting no worse or better until yesterday (like 6 days).  Yesterday while chewing, felt and heard the joint "POP."  This was followed by a pretty intensly painful spasm in the muscles of mastication.  It was almost tetanic. My jaw was frozen on the right side.  Both active and passively.  Not just by pain, but seemingly actual physical limitation in movement.

So pretty immediately it became clear I'd likely dislocated the joint.  I should mention that I also have Ehlers-Danlos, so this sort of thing is more the norm.  I've dislocate a lot of joints.

So without really thinking I grabbed my jaw and performed the manuver for an anterior dislocation (again, this is far from the first time I've reduced my own dislocation, but the first time for this joint.)  I have reduced a couple of traumatic anterior dislocations before, so I'm pretty sure it got it right.  I was actually able to reduce it very quickly.  There was a little more spasm when I did the reduction, but overall it wasn't horrible.    

Last night I awoke with a new sensation in my jaw.  The stiffness that original developed has worsened and there was a malocclusion that had be been there before the "dislocation."  I had also lost the ability to place any biting force at all on my right side.  However, I am able to fully close both sides.  Along with this had developed sensation of uncomfortable tightness and pain along the classical V2 distribution.  There is also a great deal of discomfort along the anterior aspect of my inner ear canal.  I remember learning about this referal pattern and thinking it was an interesting factoid.  However, in reality, it sucks.  Both the ear and the whole joint in general have a very odd general sensation.  It's painful when i move things quickly or in a direction they don't want to go, but more than anything is very strong discomfort of pain.  I don't know if that makes sense.  

This has persisted into today with slight worsening of the symptoms.  

So I have a few questions.  They don't really teach us anything about dental issues in med school.  It's amazing actually, because on our end we see a lot of patients with "TMJ" or tooth pain...  I can only imagine how frustrating our ill-guided attemps to treat stuff like this must be (I've never seen an MD fix anything related to dentistry).  Anyway, I digress.  

I fear at this point that there may be physical damage to the articular disc.  The right TMJ is completely unstable.    It doesn't fully dislocate, but it does sublux often.  Anything that puts pressure on the joint, in any direction, will pop the joint out a bit and send a good zap right into my brain.   

In the long term, I know I've got to do something about my grinding.  I have been taken an SSRI from some generalized anxiety and it has helped with both the anxiety and bruxism. Last year during finals I cracked a molar grinding and had to have a root canal.  Have there been any developments in bite-guards recently that might make it easy to keep one in at night?

The main question I have: is this an emergent type of situation or am I ok waiting until next week to be seen? The only way I'd be seen this weekend is in my hometown ER.  The trouble with that is obviously the holiday and that I'm supposed to be working a few shifts in the ED over break. Also, the ED docs probably won't know much more about this than I've been able to figure out.  

From what I've written, do you have general thoughts as to what might have happened (does my interpretation seem reasonable)?

Also, what's gonna be the most cost effective way to go from here?  I don't have dental insurance (though I do have some oral surgery benifits), I'm borrowing 40k a year for school, and have basically ended up spending any money I did have on the divorce/moving.  So cost is an issue.  But only to a point: gotta get this jaw moving again.

Thanks for any insight you can provide and sorry for the long question.  I just wanted to make sure I put in all the info you might need.  

Answer
Dave,

You have done an admirable job describing your situation.  Muscle trismus in the lower face can be either the cause or effect.

The healthy mandibular condyle articulates with the articular eminence of the temporal bone (not with the Glenoid fossa).  The disk serves many functions, not the least of which is to keep the two jaw bones from grating directly against eachother.  During normal opening, the condyle rotates for about the first inch of jaw opening.  To open wider, the condyle must also translate anteriorly along the slope of the articular eminence.  This is a safety net to prevent rotation of the tongue base into the airway during jaw opening.

If the TMJ disk is displaced (usually anteriomedially due to the pull of the lateral pterygoid muscle), the disk can pose a physical barrier to opening by blocking anterior translation of the condyle.  Disk displacement and/or trauma can also cause joint swelling, ligament damage, or bleeding within the joint that can impede jaw movement.

Not all internal joint disruption impedes jaw movement.  In some cases the direction of displacement, anatomy of the region, or degree of damage is amenable to adaption.  In fact, it has been estimated that 70-80% of adults will experience a click, pop, or other joint sound (meaning there has been joint disruption) over the course of a lifetime.  Most of these cause no chronic pain or functional liability.

Cramps in the power jaw closure muscles (especially the masseter, medial pterygoid, and temporalis) can also restrict jaw opening.  In these cases, a joint click or pop may be present, but is not directly related to the functional restriction.  The restriction is a muscular problem.

Some people have hypermobile TMJs.  As the condyle translates anteriorly along the articular eminence, its forward motion is limited by ligaments.  If these ligaments are too flexible, stretched, or torn, the condyle may translate too far forward and slide over the crest of the eminence.  This may cause it to become stuck forward of the crest.  This is known as dislocation.  When one or both condyles are dislocated, the teeth will not bite all the way together normally.  If the bite feels normal, there is no dislocation.

Treatment of TMJ problems requires a specific diagnosis as each type of problem is treated differently.  If your medical school has a dental school on campus, I suggest you see if they have a facial pain clinic.  In the interim, stick to a no chew diet, drink at least 64 ounces of water a day, take multivitamins, and consider nutritional supplements (in the form of puddings or shakes) to keep your calorie and protein count up.  Alternating ice and moist heat massage to the affected area can help to break up spasm.  Avoid speaking any more than absolutely necessary to give the jaw as much rest time as possible.  Poor posture strains the joint, so be aware of head and body posture.

Best wishes,

Steve