Chronic TMJ Pain and Stress

A 21-year-old white female was experiencing chronic facial pain and clicking in the left TM joint that made chewing difficult. Her doctor thought that orthodontic treatment was necessary, even thought the patient had no specific concerns about the appearance or functioning of her teeth. The problem had been present for 8 years. During this time she had multiple adjustments to her bite. An orthodontist constructed an occlusal splint designed to adjust her bite. When that did not bring any relief, she was referred to a pain clinic for evaluation and treatment. During the initial interview, it was discovered that stress made the problem worse. The patient was under considerable stress in work and family environment. She also said that she was sometimes aware that she clenched her teeth.

Her TMJ Scale Report noted significant overall TMJ symptoms and pain, joint noises and functioning problems, limitation in jaw opening and the impression that the teeth did not fit together properly. Emotional factors were not elevated, but a significantly high stress level was found. The report also indicated that clenching and sore teeth in the morning (a sign of jaw clenching and/or grinding during sleep) were found.

The physical examination found facial muscle tenderness, but not the joint clicking she had reported, even when the jaw was forced open to 45mm past the 32 mm that was comfortable to the patient. A diagnosis of MPD brought on by stress and clenching was made, with a minor click due to an anterior (to the back of the joint) disk displacement. The treatments prescribed were physical therapy, biofeedback to reduce stress, and Flexeril, to control pain.

Comment: The TMJ Scale (and the patient) reported joint noises, but the physical examination did not. This is because TMJ symptoms can be intermittent, present one day, but not the next. Because the TMJ Scale asks about recent symptoms, not just symptoms present now, it augments the physical exam and provides data that might otherwise be missed. This case also points out the importance of determining whether stress is an issue, and not just looking for a physical problem, as the patient's doctors first did.

(published in the TMJ Scale Manual 1987)

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