Dealing with the Great Imposter
By Ira Shapira, D.D.S., F.I.C.C.M.O.
Mary has been in pain for over 28 years. She has dealt with headaches, facial pain, and neck pain for as long as she can remember and has seen every neurologist and pain specialist, massage therapist, and chiropractor she has heard about from friends. She lost track of all the medications she has tried.
Joseph has had a problem with neck pain for over eight years after a car accident where there was almost no damage to his car. Chiropractic adjustments help for a few days at most. His snoring is heroic not only forcing his wife out of the bedroom but off the second floor and onto the couch downstairs.
Sue is desperate and has thought about suicide. She would never do it because of her concerns about her two young children. It is everything she can do to just make it through the day. She seems to only relate to her husband when they are fighting, and intimacy is a thing of the past. She is always bone tired even though she seems to spend more and more time sleeping. She seems to have cut off all of her family and friends, and the only thing she still has is her pain. It is the one thing she never loses.
Joyce has had three root canals and two teeth extracted due to pain. None of that work helped her pain, and now she is taking neurontin which does take the edge off. She has a cabinet full of other drugs prescribed by the myriad doctors she has seen continually for as long as she can remember. Her jaw is always tight and she feels a tight band around her head. She is often dizzy or just unstable and also has a high pitch ringing in one or both ears. It often sounds like she is underwater and she just can't clear her ears or her brain. Joyce cannot remember the last time she felt happy.
What do all of these folks have in common, why are they still suffering and why do they keep getting worse in spite of seeing the best physicians and taking the most expensive medications? They have had several CAT scans, MRIs, EMGs, and still have no definitive diagnosis and see no answer in sight.
The Reason is that they are seeing their lives pass them by because of The Great Imposter. They are all suffering from Craniomandibular Dysfunction or Temporomandibular Dysfunction or TMD. According to the National Heart Lung and Blood Institute (NHLBI) "symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function". The NHLBI estimates that it affects 12% of the population or more than 34 million Americans in 2001. The NHLBI agrees with most clinicians who find about 80% of the sufferers are women and that women generally have more debilitating symptoms than men. It is often mistakenly referred to as TMJ which is the abbreviation for the Temporomandibular Joint. TMJ is not a disease but merely the description of an anatomical joint just as knee or hip are not diagnoses but body parts.
So why do so many suffer needlessly and what is so difficult about diagnosis and treatment? The first step is to understand how many disorders are linked to TMD and what the symptoms and complaints are. Here is a partial list:
- Headaches: These may be chronic daily headaches or migraines. They may be felt at the back of the head, the temples, the top of the head, or most commonly like a tight band around the head. They are often diagnosed as tension headaches.
- Facial Pain and/ or Sinus Pain: This pain is sometimes diffuse and sometimes very specific. It is common for patients to have been treated for numerous sinus infections.
- Earache or otalgia: Pain in the ear or in front of the ear is very common.
In addition to pain there are many other symptoms related to the ears including eustacian tube dysfuntion or a feeling of water in the ears or clogged ears. Various ear noises including clicks, pops, squeaks, humming, buzzing, chirping or high pitch ringing are not uncommon. These patients, even though they feel they do not hear well, may be very sensitive to loud noises.
Dizziness, disequilibrium, and vertigo are other symptoms related to proprioception and the middle ear.
Cervicalgia (neck pain) and shoulder pain are very common.
Myalgia (muscle pain) is almost universal and may be limited to certain areas (MPD or myofascial pain) or widespread (fibromyalgia). The pain is often aching, tiring or throbbing and exhausting.
Autonomic symptoms such as irritable bowel, gastric reflux, and abdominal pain are secondarily related according to the NHLBI.
Retro-orbital pain (pain behind the eyes) is often associated with sensitivity to light.
Tooth pain, facial pain, jaw pain often going into the TM Joint are the symptoms that usually bring the patient to the dentist. Tooth extractions and root canals may help temporarily but may sometimes even worsen the condition. The answer usually comes from a dentist who understands the neuromuscular intricacies of the head, neck and stomatognathic system.
Why do so many problems seem to arise from such a small area and why is it so hard to diagnose? The first place to look is the nervous system. Approximately 20% of the input into the brain comes from the spinal column the other 80 % comes form 12 sets of cranial nerves the go directly from the brain to the body. These nerves include the nerves for sight, smell, taste, vision, hearing, eye movement and a large proportion of the nerves that go to our stomach, heart, lungs and other internal organs. Approximately 70% of the cranial nerve input comes from 1 set of nerves, the fifth nerve or the trigeminal nerve. That is more than half of all the input into the brain.
What structures do the trigeminal nerve go to? The trigeminal nerve affects teeth, the jaw muscles, the jaw joints, the lining of the sinuses, the anterior 2/3 of the tongue, the gums and lips, and the lining of the brain controlling blood flow.
To understand this effect, consider the analogy of a house with an overloaded fuse. The fuse that most often blows is the most overloaded one that goes to appliances like toasters and hair dryers. In the body the most overloaded fuse is the trigeminal nerve and when it is overloaded pain is the result. The resultant negative input to the brain affects not just the masticatory mechanisms but the entire body.
Sleep problems are common in TMD patients and according to theNHLBI, "There are reasons to suspect that TMD patients are at greater risk for cardiovascular diseases. Many patients exhibit sleep dysfunction associated with persistent pain and inability to sleep on their side, but sleeping supine (on your back)increases the risk for sleep disordered breathing. The effects of acute and persistent pain upon autonomic and nervous control of these systems would be expected to impose further cardiovascular risk to these patients."
That means that the pain and sleep disorders go hand and hand and increase your risk of death. The craniomandibular system is responsible for keeping us alive. If it fails we will not be able to breathe. This is where muscle dysfunction enters the picture. The muscles will overwork themselves to protect the whole. They do this at their own expense and they develop the muscle problems that are responsible for most pain. This dysfunction is what is known as a repetitive strain injury. It is usually referred to as Myofascial Pain and Dysfuntion. Trigger points are small areas that are responsible for referred pain, i.e. pain felt someplace other than where it is coming from. It is the referred pain that leads to so many misdiagnoses and the name, The Great Imposter.
The NHLBI also found that swallowing reflexes involving masticatory (jaw) muscles and the tongue were responsible for chronic coughing secondary to secretions accumulating being forced into the throat.
Breathing disorders related to TMD include sleep apnea and Upper Airway Reistance Syndrome (UARS). All of the body's systems fall into disarray as normal sleep is eroded.
This is a complex field where even small changes can have huge unexpected and diverse consequences . I like the analogy of having a doctor scale where you set the 50 pound and the 10 pound weights first and then the 1 pound weight is adjusted until the scale is in perfect balance. If you move that one pound weight just a little to the right or left the scale does not go just a little out of balance but rather it goes KLUNK. That is how I like to describe patients with TMD problems, They have been KLUNKED. The jaw acts as a counter balance for the head over the spine, improper head posture changes this balance and now all of the muscles of the back and spine must work overtime leading to neck, shoulder and back pain.
The tensor palatini muscle that closes off the nose when we swallow is also responsible for opening and closing our eustacian tubes. Problems swallowing create not just breathing and sleep problems but also postural distortions and ear symptoms such as pressure or water in the ear. The tensor tympani is embryologically part of a jaw muscle called the medial pterygoid muscle, and they share a nerve supply.
It is possible to track symptoms like depression and suicidal feelings to changes in the endocrine-pituitary-hypothalmic system associated with chronic pain and sleep disorders.
The good news is that there is help available. Dentists trained in neuromuscular dentistry and dental sleep medicine are well trained in treating both the pain and the sleep problems in conjunction with qualified sleep physicians. I advise seeking out dentists who are involved in ICCMO, the International College of Craniomandibular Orthopedics, and who are also Diplomats of the Academy of Dental Sleep Medicine.
The NHLBI Workshop was held on December 3-4, 2001 and is available on the internet. Make a copy for yourself and also for each of your treating physicians as many are not aware of the wide effects of this disorder.
Dr. Ira Shapira has been treating TMD with neuromuscular techniques and sleep disorders for over 25 years. He is a Diplomat of the Academy of Dental Sleep Medicine, A Dipomat of the Academy of Pain Management, a Fellow and former International Regent of ICCMO. He was a visiting assistant professor at Rush Medical School in the sleep service where he was involved in research in the mid 1980's and again in the 1990's and early 2000's when he treated sleep disorders including obstructive apnea, snoring, and Upper Airway Resistance Syndrome. He is a charter member of the Sleep Disorder Dental Society which later became the Academy of Dental Sleep Medicine; founding member of DOSA, the Dental Organization for Sleep Apnea; a lecturer for ICCMO; and a frequent lecturer at A4M, the American Academy of Anti-Aging Medicine.