The pain in your neck may well originate from your jaw. Helen Grange looks at Temporomandibular Joint disorder.

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For weeks 25-year-old Amy Kay had pain in the top left side of her mouth. She went to the dentist, who examined her teeth and took X-rays but saw nothing untoward.

Thinking it could be psychosomatic, Amy tried to ignore it, but the pain did not let up. “I would avoid chewing on that side,” she says. She went back to the dentist, but more X-rays again drew a blank. But the dentist noticed that when Amy opened her mouth wide, the jaw clicked.

She was referred to Dr Gys de Necker, a dentist with an interest in Temporomandibular Joint (TMJ) disorder. This refers to the joint between the skull (temporal bone) and the lower jaw (mandible).

“He did an X-ray and took impressions of my teeth, then diagnosed TMJ disorder. He said the problem was that my upper jaw should’ve grown out more, and that it would take about three years to fix, with the help of a plastic splint that would help pull the upper jaw forward,” she says.

TMJ disorder is not widely known about, nor is it a discipline that many dentists include in their gamut of knowledge. Yet De Necker says about 90 percent of the patients he sees have TMJ disorder to some degree, though in many cases they just need medicines to alleviate the pain and relax the jaw muscles.

“The problem with modern man is that we do not develop the upper jaw to its full potential. This is because of our refined diets, which means we no longer need a strong upper jaw to tear meat.

“So the underdeveloped upper jaw traps the lower jaw, positioning it too far backwards, in turn displacing the condyles (the round end of the jaw bone). TMJ disorder is when the condyle disc (which acts like a hinge) keeps slipping out of place. The disc jumps off the condylar head towards the back, front or sides when you open your mouth. This jumping action is heard as a click,” he explains.

TMJ disorder can cause localised pain, as in Amy’s case, but its symptoms are usually insidious and widespread.

The position of the condyle determines the way the two sets of teeth fit together, which in turn affects the person’s body posture. If TMJ disorder is present, it causes the ligaments and muscles around it to go into spasm, and the referred pain is felt in the head and neck area, as well as the back, due to a compromised body posture.

“When people are stooped forward, it is one of the immediate telltale signs of TMJ disorder,” says Dr de Necker.

But a long list of other symptoms can manifest – headaches, teeth grinding, earache, sinus pain, facial muscle pain and pain when chewing.

Other symptoms include difficulty breathing, clogged or itchy ears, lack of sleep, chronic tiredness, anxiety attacks, depression, heart palpitations and even hormonal problems.

To determine TMJ disorder, a specialist will thoroughly examine the patient and learn about their symptoms, take X-rays and impressions of the teeth and in the case of maxillofacial surgeons, may order an MRI scan to show the location of the TMJ disc in relationship to the jaw and skull bones.

De Necker does a Bimler Analysis, a measurement tool which shows the respective relationships of the cranial base to the jaws and teeth.

Treatment of TMJ disorder is not straightforward, as the specialists mainly concerned with it, namely prosthodontists (cosmetic, implant and restorative dentistry) and maxillofacial surgeons differ in their approaches.

Professor Johan Reyneke, maxillofacial surgeon at Sunninghill Hospital, says: “The causes of TMJ disorder range from mild to very serious, including ankylosis (fusion of the bones, in this case, the condyle to the skull), where the patient can’t even open their mouth beyond a few centimetres.

“The first thing to establish the exact nature of the problem. Most TMJ problems can be treated conservatively, and very seldom is surgery indicated.

Treatment typically begins with anti-inflammatories and physiotherapy, and then, depending on the response, Reyneke might make a splint – worn at night – to prevent the teeth clenching.

A soft diet is always recommended, to alleviate pressure during the treatment phase.

In more serious cases, a maxillofacial surgeon may opt for an arthroscopy, a minimally invasive surgical procedure which examines and sometimes treats the joint (like suturing the discs in place, or removing loose scar tissue).

De Necker favours using a splint initially, followed by a removable template, which is inserted into the mouth with the aim of re-shaping the mouth, the ultimate goal being to reposition the lower jaw, in turn decompressing the condyle.

“The main aim of using a splint is to decompress the condyle by pulling it down and forward, which allows the blood vessels to open, decrease pressure on the nerves and allow innervation of the limbic system,” he says.

The splint is worn at all times and is only removed to brush one’s teeth.

Next, a removable applianceis inserted on the upper jaw to develop it. “This allows the upper jaw to provide space for the lower jaw to swing into place with ease, and lessens the pressure on the TMJ,” says De Necker.

The third phase is to establish a stable bite with orthodontic treatment (moving teeth into the correct position), which normally entails braces, and perhaps crowns and/or inlays as well.

“The first two phases typically take about one year, and the third phase a year and a half, so you’re looking at up to three years,” says De Necker.

Amy, who is three months into the treatment, says she first struggled to cope with the splint. “It was horrible for the first month. My tongue kept feeling around as if to try to remove it and it affected my speech, but I’ve got used to it now,” she says.

She also goes to physiotherapy once or twice a month to release the tension in her neck, shoulders and lower back, all symptoms of TMJ disorder. The pain in her mouth has gone, however.

“I’m glad I’m on this journey, though, because it also prompted me to change my diet and look after myself better.

Stress, says Reyneke, is the biggest culprit behind pain around the termporomandibular joint.

“It causes people to clench their jaws. I call it ‘Gauteng Syndrome’, because the incidences of it increases in November and beginning of December, when people are on deadlines and students are writing exam,” he says. “When they go on holiday, it decreases.

To find a prosthodontist, visit the Academy of Prosthodontics

To find a maxillofacial surgeon, visit the SA Society of Maxillofacial and Oral Surgeons