Pat French woke up one morning recently and couldn't open her jaw without pain.
"I tried ice, heat, but it didn't help," says the 61-year-old Grants Pass woman.
French headed for the dentist, who referred her to a physical therapist. Her condition is one of several that are known collectively and popularly as TMJ, short for temporomandibular joint disorder — a real mouthful.
The diversity of symptoms and causes make TMJ difficult to diagnose and treat. The American Academy of Orofacial Pain wrote that TMJ "usually involves more than one symptom and rarely has one cause."
According to a practice survey the academy conducted in 1999, 89 percent of dental specialists chose to refer patients experiencing chronic jaw pain rather than treat them themselves. The primary reasons given were insufficient training and complexity of the cases.
Fortunately for French, her dentist knew of a Medford physical therapist who has treated TMJ patients since 1981 and who has developed nonsurgical techniques for treating jaw pain.
One of the first questions physical therapist Bill Esser asked French was whether she had experienced trauma to her face as a child. It turned out she had run into a steel beam and broken her nose and teeth as a 12-year-old. One of the tip-offs of past trauma, according to Esser, is a scar under the chin.
"Teens are always falling off bicycles, skateboards. It can lead to degenerative changes in the jaw if not treated quickly and can lead to TMJ later (in life)," says Esser, a partner at Jackson County Physical Therapy in Medford.
The TMJ is the joint that connects the jaw bone — the mandible — to the skull. Inside the joint is a delicate disc that can be displaced during trauma and cause tremendous pain.
"The standard treatment of care for dentists for acute trauma to the jaw is first, medications and send the patient home, and having them ice the jaw. Second, put a splint in the mouth. But this doesn't address the problem of the mandible in relation to the disc. Finally, arthrocentesis is prescribed if there is no treatment," Esser says.
TMJ arthrocentesis is a surgical procedure in which fluid is inserted into the temporomandibular joint with a needle to lubricate and allow freer movement of the joint and disc.
The key to avoiding surgery is to treat the trauma quickly.
"MRI studies show that if patients are not seen in three to four weeks, the discs are permanently displaced. In kids and teenagers, the mandible stops growing on one side and can lead to facial asymmetry — the teeth contacts are not the same on both sides of the face," Esser explains.
These problems can lead to grinding the teeth or an arthritic jaw later in life.
Medford orthodontist Ted Bennion often refers patients to Esser and often helps other dentists diagnose TMJ. He owns equipment that takes CT scans of the head. Dentists all over the Rogue Valley have sent TMJ patients to Dr. Bennion for tests.
"I've looked at close to 2,000 scans. The disc looks like a Frisbee. When it deforms, it begins to look like a football — and that doesn't fit well. Once this happens, we can't get that shape back, we can't re-elasticize the fibers," Bennion explains.
Esser's treatment for trauma-based TMJ is often a manual adjustment.
"We push the jaw straight down and, in many cases, the disc will pop back into place. Then we build a temporary splint to stabilize the jaw. We send them to a dentist for a permanent splint — a night guard — and this keeps a space open so you can't squish your disc," says Esser.
As many as 90 percent of patients seeking treatment for TMJ are women, the New York Times reported last February. And many of these, like French, don't begin to experience symptoms until middle age.
"TMJ is a female issue because of hormone changes — women's ligaments are softer — everything is strained and more susceptible to microtrauma," says Esser.
This microtrauma is the result of accumulated damage to the soft tissue in the jaw over many years. Esser estimates that microtrauma accounts for three times as many cases of TMJ disorder as sudden injury. Microtrauma can result from mouth breathing, incorrect posture or from chewing gum.
"There is 50 percent more disc displacement in teenagers who chew gum, especially girls. Teeth should be in contact (from chewing food) five to 15 minutes a day. If you're chewing gum for four to eight hours, you're smashing your joint," Esser cautions.
"Don't overload the jaw joint," warns Bennion. "If your jaw is hurting, don't chew gum or things that are hard to chew."
Further treatment consists of retraining the patient to chew and open the mouth properly, and to maintain good posture. These treatments are especially important for patients who develop TMJ later in life, long after a trauma, or for those who have never experienced trauma to the jaw.
Fortunately for French, her treatments provided relief relatively quickly.
"I'm 99 percent better after four treatments. In the first treatment, they gave me ultrasound, nerve stimulation and manually manipulated my jaw. I have visited once a week for four weeks," French says.
She now wears a night guard and practices putting her tongue on the roof of her mouth before opening it.
"I'm learning to open my mouth differently after 60 years of opening and closing it a certain way," French explains. "It will take some training."