U.S. Air Force Loadmaster MSgt Terrell Davis* had experienced headaches since he was 15-years-old. He had seen numerous specialists, tried medications, physical therapy, chiropractic adjustments and yoga. He had been diagnosed with migraine and tension type headaches, fibromyalgia, chronic fatigue syndrome and half-a-dozen rule-outs. At 32-years-old, he had suffered head pain for more than half his life and it was getting worse, affecting his work and his personal life. He described his headaches as usually starting in the right temple, but they would often spread all around his head and down his neck and shoulders. He would often wake with the headache in the morning and sometimes it would wake him in the middle of the night. MSgt Davis reported that his symptoms worsened following his two deployments and his recent divorce. In his most recent deployment, he reported being hit in the head and face by a loose strap from a failed drogue parachute deployment. Finally, at a dental appointment MSgt Davis’ provider noted evidence of grinding of his teeth, especially on the right side and diagnosed him with Temporomandibular Joint Disorder.
*Not their actual name
The Temporomandibular Joint is probably not the first thing that comes to mind when you think about joints of the human body. Most people will think first about hips and knees then maybe wrists, ankles and fingers, but one of the most utilized joints in the body are the temporomandibular joints or TMJs. The TMJs open and close the mouth approximately 2,000 times a day (and clearly more in some people). In addition to talking and chewing, the joints also work to show a range of non-verbal communications including expressions of joy and sadness and play a role in kissing and other expressions of intimacy. The TMJs are located just in front of each ear and connect the mandible or lower jaw bone to the temporal bones of the skull. The muscles controlling the joints are attached to the mandible and allow the jaw to move up, down, side-to-side and forward and back. The condyle is the rounded end of the mandible that sits inside the joint socket at the base of your skull. In a healthy jaw, a soft, fibrous disk lies between the condyle and the socket and absorbs shock and pads movement within the socket. The combination of synchronized movement between the joints on each side of the skull and the ability of the jaw to move in multiple dimensions are unique and make the TMJ the most complicated joint in the body.
Temporomandibular Joint Disorders (TMD) go by a range of names and acronyms including TMD, temporomandibular joint and muscle disorders (TMJD) or sometimes just TMJ and represent a set of more than 30 health disorders of the TMJ. TMJDs are the second most commonly occurring musculoskeletal condition resulting in pain and disability after chronic low back pain, affecting 5-15% of the population, yet they are commonly disorders of exclusion, underdiagnosed and undertreated. Historically, epidemiological data and a recent systematic review and meta-analysis (Goncalves et al 2010 and Bueno, et al 2018) have indicated TMD to be as much as two times more common in women. However, longitudinal data have found little gender difference (Slade et al 2013). In a study of U.S. military veterans, Fenton et al., (2018) noted that the odds of TMD were higher in men of Hispanic ethnicity compared to white and other non-white males with lower odds for black and Hispanic women compared with white women. Age distribution of TMDs show two distinct age peaks with the most common being under age 25 and often associated with disc displacement without arthritis or other degenerative disorders and the other being older adults with arthritis or other inflammatory disorders. No clear racial/ethnic differences have been reported to date although this is likely due to study samples rather than actual incident rates. Because TMJDs often occur along with a wide range of inflammatory disorders and conditions, including headaches, sleep apnea, arthritis, hypertension, irritable bowel syndromes and disorders, asthma and ankylosing spondylitis to name a few, they are often identified as part of a constellation of pain disorders called chronic overlapping pain conditions (COPC). According to TMJ.org, a TMJ advocacy website, as many as 85% of people with TMJDs also suffer from chronic pain or other non-pain conditions throughout the body. In fact, the Orofacial Pain Prospective Evaluation and Risk Assessment Study (OPPERA) indicated that one of the strongest predictors of first onset TMD was the number of comorbid pain conditions (Slade, et al, 2011). In addition to medical comorbidities, TMJDs are often associated with mental health comorbidities including depression, anxiety, insomnia and PTSD.
There is very little published data related to the specific prevalence of TMD in U.S. military, however studies looking at military members of other countries consistently find TMD to be prevalent in military members and consistently more common than in the general public. Several studies have investigated the relationship between PTSD and TMD both in the general population and in U.S. military and veteran samples and have found that subjects with PTSD have significantly higher rates of TMJD than non-PTSD military members and veterans (see Mottaghi, 2014 and Vanecek, 2011).
Treatments for TMJD vary widely depending on the etiology of the TMJ pain and factors that may be exacerbating or maintaining the problem. Currently, no clinical practice guidelines exist for TMJD. Patients often struggle to get a diagnosis and spend years in pain seeking diagnosis and effective treatment. While it has been noted that perhaps only 5-10% of patients require treatment for TMJD and that as many as 40% of patients have spontaneous resolution of symptoms. In one study of people who developed TMJD (Slade et al., 2016), 57% reported receiving one or more treatments during a six-month period. In one long-term follow up study, 50-90% of patients had pain relief with conservative therapies (Indresan & Alpha, 2009).
Treatments range from self-management and conservative treatments to medications, injections and open surgery. Most experts suggest that treatment should begin at the most conservative, non-surgical treatments before progressing to surgery as a last resort. Most current TMJD treatments lack strong evidence to support or reject their use. There are two exceptions to this finding and those are self-management, which has strong support in general pain literature, and occlusal treatments which, despite a large body of research, lack consistent evidence to support their use. With regard to self-management, therapist-guided Cognitive Behavioral Treatment and Biofeedback have the most consistent support (Aggarwal et al., 2019). Most guided self-management (CBT) treatments focus on habit identification and reversal (nail biting, jaw posture, clenching etc), relaxation and/or meditation training, cognitive restructuring to identify and change overly negative thoughts and problem solving or stress management techniques. Biofeedback approaches focus on using EMG biofeedback to reduce masseter muscle activity. Other treatments include physical treatments such as occlusal adjustments and orthodontic treatments, physical therapy, complementary treatments such as acupuncture and diet (soft food) changes, pharmacological treatments, including pain medications and antidepressants, and interventional treatments including arthrocentesis, open surgery and TMJ implants. The National Academies of Sciences, Engineering, and Medicine’s Temporomandibular Disorders: Priorities for Research and Care (2020) is an excellent resource for further information regarding diagnosis, treatment and future research directions regarding TMJD. The takeaway key for patients is to be informed about your diagnosis and the treatment options based on your diagnosis. Ask your provider about the risks, limitations and studies (hint: there are not many) regarding any recommended treatment and always advocate for the least invasive treatment first.
MSgt Davis’ dentist referred him to the Clinical Health Psychology program for self-management training. He attended one open group psychoeducational session led by his dental provider and a clinical health psychologist held at the dental clinic. Attendees were provided information on TMJD and the rationale for habit identification and reversal and were introduced to the DefeatTMD method to detect jaw tension and then to Drop the jaw, separate the Teeth approximately the width of the pinkie or a pencil, relax the Masseter muscle and take a Deep breath. Attendees were given cards with the DTMD mnemonic to place around their environment as reminders and trained in diaphragmatic breathing. MSgt Davis had three individual sessions that focused on his specific pain situations and cognitions related to his pain. At a follow-up joint dental/psychology appointment six months following treatment he noted a significant reduction in jaw and facial pain and reported no headaches in the last four months. “I know now that I had a couple of bad habits that contributed to this problem regardless of what started it or made it worse. I had started biting my nails as an adolescent. I also had a tendency to prop my head up on my hand when I’m sitting at my desk and would fall sleep on flights with my head in my hands putting pressure on my jaw. I also tended to clench my jaw a lot especially when under stress. While these habits and behaviors may not have caused the TMD, I know now that they contributed to its worsening and learning new behaviors and ways of thinking about situations made it better.”
Editor's note: For more resources and information on the topic, check out this month's Chronic Pain spotlight page here.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
William Brim, Psy.D., is the director of the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. He joined CDP in 2007, initially as a deployment behavioral health psychologist at Malcolm Grow Medical Center and served as deputy director until 2017.
References and some follow up reading…
Aggarwal VR, Lovell K, Peters S, et al. (2011). Psychosocial interventions for the management of chronic orofacial pain. Cochrane Database Syst Rev. (11): CD008456.
Aggarwal, V. R., Y. Fu, C. J. Main, and J. Wu. (2019). The effectiveness of self-management interventions in adults with chronic orofacial pain: A systematic review, meta-analysis, and meta-regression. European Journal of Pain 23(5):849–865.
Bueno, C.H., Pereira, D.D., Pattussi, M.P., Grossi, P.K., & Grossi, M.L. (2018). Gender differences in temporomandibular disorders in adult populational studies: A systematic review and meta‐analysis. Journal of Oral Rehabilitation, 45, 720–729.
Fenton B.T., Goulet J.L., Bair M.J., Cowley T., Kerns R.D. (2018). Relationships between Temporomandibular Disorders, MSD conditions, and mental health comorbidities: Findings from the Veterans Musculoskeletal Disorders Cohort. Pain Medicine, Sep 1;19(suppl_1):S61-S68. doi: 10.1093/pm/pny145. PMID: 30203016.
Goncalves DA, Dal Fabbro AL, Campos JA, Bigal ME, Speciali JG. (2010). Symptoms of temporomandibular disorders in the population: An epidemiological study. Journal of Orofacial Pain, 24(3):270–8.
Indresano A, Alpha C. Nonsurgical management of temporomandibular joint disorders. (2009). In: Fonseca RJ, Marciani RD, Turvey TA, eds. Oral and Maxillofacial Surgery. 2nd ed. St. Louis, Mo.: Saunders/Elsevier; 881-897.
Mottaghi A, Zamani E. (2014). Temporomandibular joint health status in war veterans with post-traumatic stress disorder. J Edu Health Promotion;3:60.
National Academies of Sciences, Engineering, and Medicine (2020). Temporomandibular Disorders: Priorities for Research and Care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25652.
Slade, G. D., Bair, E., By, K., et al. (2011). Study methods, recruitment, sociodemographic findings, and demographic representativeness in the OPPERA study. The journal of pain, 12(11 Suppl), T12–T26. https://doi.org/10.1016/j.jpain.2011.08.001
Slade GD, Bair E, Greenspan JD, et al. (2013). Signs and symptoms of first-onset TMD and sociodemographic predictors of its development: The OPPERA prospective cohort study. The Journal of Pain, 14(12):T20–32.
Slade, G. D., R. Ohrbach, J. D. Greenspan, R. B. et al., (2016). Painful temporomandibular disorder: Decade of discovery from OPPERA studies. Journal of Dental Research 95:1084–1092.
Vanecek, R., Talcott, G., Tabor, A., Mcgeary, D., LANG, M., & Ohrbach, R. (2011). Prevalence of TMD and PTSD symptoms in a military sample. Journal of Applied Biobehavioral Research. 16. 10.1111/j.1751-9861.2011.00069.x.