Diagnostic and Treatment Approaches for TMJ

Hi Dr. Nagler,

After six months with Tinnitus, I have reached a point where various doctors (my otolaryngologist, general practitioner, dentist, chiropractor, and neurologist) all agree that my Tinnitus is being exclusively caused by muscle spasms in my head, neck, jaw, or upper back. They have termed this generally as TMJ dysfunction, but they have cautioned me that this is often times a "catch-all" for all neuromuscular inflammatory conditions caused by muscular and skeletal problems in the region and that all muscles in the head, neck, shoulder, and upper back are deeply intertwined. I have been able to completely silence my Tinnitus using a standard 7-day taper of prednisone; I have been able to also almost totally eliminate my Tinnitus by using NSAIDs combined with anti-spasmodics. I do not want to be on drugs forever, however, and in some cases, these can just cause other problems.

I will be seeing, at @Carlos1's encouragement, Dr. David Keith in July; Dr. Keith has a worldwide reputation for treating and curing people of TMJ, and has considerable experience with TMJ-caused Tinnitus. However, his approach tends to be surgical (he is a surgeon, after all), whereas I have generally read that most surgeries don't actually cure neuromuscular inflammation caused by TMJ -- they just address the underlying muscular and skeletal problems exacerbating them.

If you were in my position, what sort of approaches would you take heading into a meeting with Dr. Keith? What sort of questions should I ask about diagnostics and treatments at this stage?

Thank you!

 

Ooooo. You are asking me to step into some quicksand, although you are not aware of it.

Let me start by repeating the questions that I would ask any person claiming to be able to treat tinnitus - be it CBT, TRT , TAT, NTT, TMJ, or any of the alphabet soup that you might read about:

· What is the approach the clinician is recommending and why?
· What type of training has the clinician undergone in the use of that approach?
· How long has the clinician been using the approach?
· How many tinnitus sufferers has the clinician treated with the approach?
· What is the clinician's success rate using the approach?
· How does the clinician define and measure success?​

OK. Now that the easy part is out of the way, let me talk to you about tinnitus and TMJ ... or more properly TMJD. And most of what I am going to say is personal opinion. OK?

So the TMJ is a hinged joint. It is where your upper jaw meets your lower jaw. Every time you open and close your mouth, your TMJ (temporo-mandibular joint) is involved. And everybody has two of 'em - one on each side of the head. Moreover, since the TMJ is involved every time you open and close your mouth - like when you talk or chew, for instance - over a lifetime the TMJ is subject to wear and tear. The TMJ can also go out of alignment, but that is much less frequent than the wear and tear - because everybody gets the wear and tear. With me so far? Nobody has a normal TMJ - because every TMJ has wear and tear.

OK. Fortunes - no, let me rephrase that: FORTUNES - have been made thanks to this little hinged joint. Elegant mountain chalets have been built, luxurious yachts have been purchased, candlelight dinners for two in Paris followed by breakfasts in Rome followed by lunches in Istanbul and beyond have been consumed all courtesy of the TMJ. Why? Because every time something the least bit wrong above the shoulders that cannot be otherwise readily explained anatomically or physiologically, the following mantra is invoked: "Well, it could be your TMJ." And it could indeed be your TMJ - but 99.99% of the time it ain't! The problem is - most of the time ya just can't tell. (I can already smell the dollars!)

Does TMJD (temporo-mandibular dysfunction) ever happen? Sure it does. The joint can go out of alignment or the normal wear and tear can lead to painful arthritis - but when that stuff happens, it HURTS LIKE HELL to open and close your mouth. Can, for instance, tinnitus be related to TMJD? Yea, I guess. But in the absence of PAIN when you open and close your mouth, that is one helluva stretch. And even if it does hurt when you open and close your mouth, most tinnitus still has absolutely nothing whatsoever to do with your TMJ. "But what about the fact that when I take the palm of my hand and push upwards firmly on my chin against resistance and as a result my tinnitus gets slightly louder until I release?" you ask, "What does that mean?" It means absolutely nothing - because it happens to almost everybody due the temporary increase in intracranial pressure resulting from the accompanying Valsalva. Yea. Like I said: FORTUNES!

So where does that leave us? Well, in my opinion it leaves us with ... Ta dah! ... Stringplayer's Third Law. And before I close with Stringplayer's Third Law, yes - I am sure there are exceptions. But I am willing to bet that they are few and far between. Finally, please let me remind you again that what you are reading is strictly an opinion piece, OK?

Stringplayer's Third Law:

If you are considering having a TMJ procedure performed because of your tinnitus, and you have no pain when you open and close your mouth, don't do it. You will be wasting your time and your money. If you do have pain when you open and close your mouth, then have the procedure performed only if the pain itself compels you to do so - and consider any benefit that might remotely result in terms of your tinnitus to be a welcome bonus rather than a reason to undergo the procedure in the first place.​

Here's to quieter days ahead for all!