TMJ: The other symptoms: Neck pain, muscle spasms, myofascial pain, breathing problems, digestive disorders and dizziness

In many patients who come to our center, we see primary problems related to neck pain and cervical instability. One of the symptoms of these problems is temporomandibular pain disorders. We also see a lot of people with primary problems with the temporomandibular joint. One of the symptoms of this problem is cervical neck pain. Surprisingly, despite the research suggesting the connection, many patients were not made aware that their jaw pain could be a problem originating in the neck and their neck pain can be a problem originating in their jaw, and with this, can come a myriad of symptoms and conditions beyond jaw and neck pain.


Part 1 TMJ and neck problems have long been linked together

  • Temporomandibular pain disorders and neck problems have long been linked together.
  • Doctors detail the connection between neck pain and TMJ disorders, going further to demonstrate a connection between neck pain and people who suffer from asymptotic TMD.
  • Condition / Symptom:
    • Forward Head Posture and TMJ.
    • Progressive TMJ osteoarthritis, Forward Head Posture, Reduced Airway dimensions.
    • The TMJ altered your posture by stressing your cervical spine. Isn’t posture a problem of swallowing and breathing difficulties?
  • TMJ disorders impact the cervical, thoracic, and lumbar spines.
  • Progressive TMJ osteoarthritis, Forward Head Posture, Reduced Airway dimensions.
  • The problems with breathing.
  • Understanding the TMJ temporomandibular joint itself. What are we seeing in this image?
  • The TMJ altered your posture by stressing your cervical spine. Isn’t posture a problem of swallowing and breathing difficulties?
  • Craniocervical muscle problems in older patients with myofascial temporomandibular pain disorders.
  • Cervical Muscle Tenderness in Temporomandibular Disorders.
  • Jaw pain, neck pain, dizziness, headache, tinnitus.
  • TMJ is a cause of dizziness.
  • Otolaryngologists fail to diagnose TMD as a source of the problem.
  • One of the easiest ways to understand how TMD and upper cervical instability affect balance and various symptoms is to consider the Eustachian tube and the vagus nerve.
  • Is it eustachian tube dysfunction or TMJ dysfunction?
  • TMJ and Fibromyalgia.
  • TMJ and Scoliosis.
  • Irritable Bowel Syndrome, gastrointestinal distress, and TMJ syndrome.
  • TMJ dysfunction and Lyme disease.

TMJ and neck problems have long been linked together

It has long been known that there is a strong association between neck disability and jaw disability. To put it another way, whenever the neck is affected by a structural issue, it affects the jaw and vice versa. Despite TMJ and neck problems being linked together, it is not often that a patient will report to us that their previous healthcare providers made this connection between their TMJ problems and their neck pain and offered treatments addressing both concerns. In the following research the links and the treatments for both TMJ problems and cervical neck instability point to a problem in the neck.

Ct Scan Of A Patient With Malocclusion

CT Scan Of A Patient With Malocclusion

In the medical journal Clinical Oral Investigations, (1) oral surgeons in Belgium made this connection between TMJ and cervical instability. This research is from 1998, so the problems of TMJ and neck disorders are hardly a new idea. We will bring this research forward 26 years to 2024.

The researchers conducted a study looking for possible correlations between clinical signs of temporomandibular disorders (TMD) and cervical spine disorders.

  • Thirty-one consecutive patients with symptoms of TMD and 30 controls underwent a standardized clinical examination of the masticatory system, evaluating the range of motion of the mandible, temporomandibular joint (TMJ) function, and pain of the TMJ and masticatory muscles.
  • Afterward, subjects were referred for clinical examination of the cervical spine, evaluating segmental limitations, tender points upon palpation of the muscles, hyperalgesia, and hypermobility.
  • The results indicated that segmental limitations (especially at the C0-C3 levels) and tender points (especially in the sternocleidomastoideus and trapezius muscles) are significantly more present in patients with TMJ than in the control subjects.

Doctors detail the connection between neck pain and TMJ disorders, going further to demonstrate a connection between neck pain and people who suffer from asymptotic TMD.

Let’s now jump to a 2021 paper, citing this research. Publishing in the journal BioMed Research International (2) and led by the Orthopaedic and Rehabilitation Department, Medical University of Warsaw, Poland, doctors detailed the connection between neck pain and TMJ disorders, going further to demonstrate a connection between neck pain and people who suffered from asymptotic TMD. Here are the learning observations:

“In most (patient) cases, it is difficult to identify the cause of neck pain (as one clear factor), which is a substantial obstacle when customizing congruent therapy and preventing further recurrences. Chronic idiopathic neck pain is defined as neck pain lasting more than 3 months, without the presence of trauma, cervical hernias with clinical symptoms, or radiculopathy. On the basis of its etiology, it was divided into specific neck pain, trauma-induced neck pain, and idiopathic (nontraumatic) neck pain. The complicated anatomical structure of the cervical spine, its complex biomechanical function, close proximity of nervous system structures, and symptom inhomogeneity (mysterious and accountable symptoms) are a challenge for clinicians and researchers dealing with diagnostics and treatment of neck pain.”

Let’s stop here for a simple recap.

  • Doctors may find it difficult to determine the cause of idiopathic or unexplainable neck pain.
  • The cervical spine is complicated and because it contains the nervous system structures, there can be a myriad of mysterious symptoms, such as described throughout this article.

The TMJ connection

“Some (researchers) have reported a relationship between craniofacial and neck pain, including biomechanical, neuroanatomical, and neurophysiological aspects. Close anatomical connection of the cervical spine to the masticatory system and frequent comorbidity of the neck and temporomandibular joint dysfunction (TMD) suggest the need to study the relationship between these areas.

Incorrect tension of the masticatory muscles was found to be associated with head posture and was suggested as one of the causes of dysfunctions in cervical paravertebral muscles. The possible explanation could be the neurophysiologic connections between the cervical spine and temporomandibular area, such as the convergence of trigeminal and upper cervical afferent inputs in the trigeminocervical nucleus.”

Let’s stop here for a recap.

What the researchers are suggesting is that there is a connection between problems of the cervical spine and TMJ, and as the doctors of 1998 suggested, here in this 2021 paper the connection needs to be explored. They also point out the problems of the trigeminal nerve.

In our article Non-surgical treatment for Trigeminal Neuralgia: I discuss why we examine the neck of a patient who comes in for a Trigeminal Neuralgia consultation. Here I write:

We examine the neck of a patient who comes in for a Trigeminal Neuralgia consultation because we are looking for compression of the nerve.  The head and neck, as all parts of the body, live in complex relations. Something in the neck can cause problems in the jaw, face, shoulders, fingers, etc. Problems in the jaw can cause problems in the neck. Any musculoskeletal problem can cause problems of headaches. Back to the keyword compression. We are looking for problems in the neck that can be influencing problems of the head and jaw. When a physician and a patient believe that a nerve is getting compressed, it is easy to see why surgery would be recommended. Unfortunately, when cervical neck instability is the cause of neuralgia, the surgery does not help relieve the pain. Cervical instability can also be responsible for almost all painful neuralgias of the head and face including occipital and trigeminal neuralgia,  as well as structural headaches including tension, migraines, and clusters. This is not a new concept for us, the examination of the cervical neck area is a crucial component of our comprehensive non-surgical Trigeminal Neuralgia program.

Posture and muscle strength

An April 2024 study (3) from Turkish researchers suggests: “It has been concluded that TMJDs with jaw and neck pain seem to negatively affect muscle strength and proprioception (your body’s ability to move without thinking about moving) of the TMJ and cervical region, postural stability, endurance of deep neck flexors and mandibular functions. Considering the strong connections between the TMJ and the neck region, evaluating not only jaw pain but also neck pain in patients with TMJDs is clinically important in terms of improving proprioception and postural stability.

Forward Head Posture and TMJ

The forward head posture has many negative effects on the body, but it is especially harmful to the TMJ and upper cervical spine. Forward Head Posture is both a cause and a symptom of ligament weakness in the neck. Weakness of the neck ligaments commonly occurs because most people spend a good portion of their days looking down at phones and hunched over while working. Their work may consist of typing on a computer or being constantly tethered to their mobile devices for many hours per day, as well as the huge surge in computer gaming. Increasing amounts of patients have suffered from “text neck.” All of these tech activities precipitate the head-forward position and put the cervical vertebral ligaments in a stretched position. Over time, these ligaments weaken and cause pain (creep). The ligament laxity causes an even more head-forward position, as the ligaments can no longer keep the cervical vertebrae in their proper posterior alignment. The paracervical muscles (the neck muscles) tighten to stabilize the joints and head. As the muscles tighten, they create more pain.

What are we seeing in this image?

A description of the vents depicted is below the image. The caption explains: A forward head posture shows one mechanism by which passive tension (the ligaments and muscles have a “stretched” resting position) in selected suprahyoid and infrahyoid muscles alter the resting posture of the mandible. The mandible is pulled inferiorly and posteriorly changing the position of the condyle within the temporomandibular joint, Also in this image note the relationship between the cervical spine and the shoulder.

The above also explains why forward head posture is so damaging to the TMJ. Habitual head forward posture is a well-known etiological cause or contributing factor of craniofacial, craniocervical, and craniomandibular syndromes. As the head goes forward with habitual sitting and looking at a computer screen or down at a smartphone, the anterior muscles of the neck tighten. This causes a shortening of the inferior hyoid muscles, pulling the hyoid bone inferior. This causes a lot of stretching or tension on the suprahyoid bone to keep the hyoid bone in place.

This tension on the suprahyoid bone causes the mandible to retract, which forces the mandibular to condyle posteriorly (backward). Remember from above that the poor lateral pterygoid muscle, as the main protractor of the mandible, has to go against the powerful temporalis and masseter muscles that retract the mandible. So in addition to this, the habitual forward head posture, also retracts the mandible, further causing a “stretching” or contraction of the lateral pterygoid, and the articular disc is again forced anteriorly by the posterior moving condyle. To counter the pull on the disc, the lateral temporomandibular ligament stretches. Eventually, it gets stretched out too much, resulting in TMJ instability.

As a person loses cervical lordosis in the lower cervical vertebrae because of a forward head posture or trauma-inducing posterior ligament complex injury, the C1-C2 vertebrae become more lordotic or have too much inward curve.

In April 2021, doctors in China published their findings (4) on the investigation of the differences in forward head posture between patients with temporomandibular disorders and healthy people. These researchers found that compared with healthy people, TMD patients present more forward heads with abnormal head and neck posture.

A January 2023 paper in the Clinical oral investigations (5) examined whether forward head posture contributes to TMD symptoms. Findings, they suggest, remain unclear. The researchers assessed 145 patients diagnosed with TMD. Patients were divided into either the forward head posture group or the non-forward head posture group. Differences in the masseter and temporalis muscle pressure pain thresholds between the two groups were analyzed.

  • No significant difference in masseter and temporalis muscle pressure pain thresholds was found between the two groups.
  • No correlation was found between forward head posture and masticatory muscle pressure pain thresholds. (Forward head posture did not put pressure on the masticatory muscles.)
  • A significant association was found between the neck muscle and masticatory muscle pressure pain thresholds.
  • Conclusion, the presence of neck pain, not the degree of forward head posture, in patients with TMD is of significance.

It should be pointed out that the above research is questioning forward head posture as the main factor for TMD problems. In many patients we see, they suffer from many problems and for many, it is the neck pain that is the “ground zero.” A December 2023 study (6) from Chile which suggests other problems can first lead to forward head posture. “Bad habits, such as poor posture during the use of technological devices, poor abdominal control and oral breathing pattern can lead to a forward head position, which has important implications for the entire future of the individual, especially at the stomatognathic system. There is a strong association between temporomandibular disorders and forward head syndrome. Where the muscular component is the main affected, with the appearance of more trigger points at the level of the sternocleidomastoid muscles (head tilt muscles in the neck), upper trapezius (common neck muscle injury), rectus capitis posterior (neck muscles that allow head forward and backward movement) and upper oblique capitis (helps maintain position of head).”

Progressive TMJ osteoarthritis, Forward Head Posture, Reduced Airway dimensions

A December 2020 study published in the Journal of Oral and Maxillofacial Surgery (7) sought to investigate associations among progressive temporomandibular joint osteoarthritis, airway dimensions, and head and neck posture. In this study, 114 temporomandibular disorders patients were examined.

  • Among the 114 patients:
    • No TMJ osteoarthritis – 28 patients had no pathologic bony changes (bone spurs) in the TMJ condyles
    • 45 had progressive TMJ osteoarthritis
    • 41 had TMJ osteoarthritis which had not progressed for 12 months.

The finding here was that forward head posture seemed to be worsening more in the progressive TMJ osteoarthritis than in either the No TMJ or TMJ osteoarthritis had stopped progressing group. (Side note: If you stop TMJ osteoarthritis progression this can help stop forward head posture.)

The problems with breathing

The researchers found: The volume (size opening) change of the oropharynx (the back part of the throat) in a supine (lying face up) position was more prominent in the progressive TMJ osteoarthritis than in the TMD no osteoarthritis patient but no significant differences in changes in the pharyngeal airway (that part of the pharynx that regulates airflow) while in an upright position was detected. – Meaning: Progressive TMJ osteoarthritis may have associations with retrognathia (the improper position of the mandible) and decreased oropharyngeal airway volume in the supine (laying down) position but not in the upright position. Progressive TMJ osteoarthritis may be related to altered head posture in the upright position to compensate for reduced airway dimensions. (The TMJ is changing your head posture so you can breathe.)

Understanding the TMJ temporomandibular joint itself. What are we seeing in this image?

In this simplified view of the TMJ, we can get an understanding of the mechanisms behind TMJ disc displacement. When this person would close their mouth, they would get the characteristic clicking sound and accompanying “pop” or feeling of displacement. See that the disc in this image has ligaments behind it. The ligaments are there to provide structural stability between the jaw bone at the skull. The ligaments are holding the jaw to the skull. In front of the disc towards the face are the powerful jaw muscles. Attaching these power muscles to the jaw are the muscle tendons. Notice how the muscle turns white as they approach the bone. The tendons are the muscles attached to the bones and they are white. They hold the muscles to the jaw. If the ligaments or tendons are weak, damaged, stretched out, or lax, the jaw is floating, and the disc can be displaced.

In this simplified view of the TMJ, we can get an understanding of the mechanisms behind TMJ disc displacement. When this person would close their mouth, they would get the characteristic clicking sound and accompanying "pop" or feeling of displacement. See that the disc in this image has ligaments behind it. The ligaments are there to provide the structural stability between the jaw bone at the skull. The ligaments are holding the jaw to the skull. In front of the disc towards the face are the powerful jaw muscles. Attaching these power muscles to the jaw are the muscle tendons. Notice how the muscle turns white as they approach the bone. The tendons are the muscles attachments to the bones and they are white in color. They hold the muscles to the jaw. If the ligaments or tendons are weak, damaged, stretched out, or lax, the jaw is floating, the disc can be displaced.

The temporomandibular joint connects the mandible (lower jaw) to the part of the skull known as the temporal bone. The joint allows the lower jaw to move in all directions so that the teeth can bite off and chew food efficiently. Temporomandibular joint ( TMJ ) syndrome occurs when the joints, muscles, and ligaments involved do not work together properly, resulting in pain.

Temporomandibular joint syndrome and TMD or TemporoMandibular Disorders have been demonstrated to be caused by ligament weakness in many patients, often as a result of clenching the jaw or grinding the teeth, sleeping position, or a forward-positioned mandible (lower jaw).

Malocclusion, or a poor bite, places stress on the muscles and may also lead to temporomandibular joint syndrome, as may an injury to the head, jaw, or neck that causes displacement of the joint. If left untreated, jaw osteoarthritis can result.

The TMJ altered your posture by stressing your cervical spine. Isn’t posture a problem of swallowing and breathing difficulties?

Let’s make one more connection as observed by doctors writing in the European Journal of Orthodontics (8).

  • In this study, the doctors compared the mandibular stress distribution and displacement of the cervical spine. In simple terms, how TMJ instability and hypermobility of the jaw negatively affected the cervical spine.
  • What did they find? “(an) imbalance between the right and left masticatory muscles antagonistically act on the displacement of the cervical spine, i.e. the morphological and functional characteristics in patients with mandibular lateral displacement may play a compensatory role in posture control.”

The TMJ altered your posture by stressing your cervical spine. Isn’t posture a problem of swallowing and breathing difficulties?

Cervical Muscle Tenderness in Temporomandibular Disorders

Cervical Muscle Tenderness in Temporomandibular Disorders

A 2020 study appearing in the Journal of Oral & Facial Pain and Headache (9) examined 192 patients with TMD and cervical muscle tenderness. What they found was cervical muscle tenderness was notable only in those with a myogenous (muscle problems) TMD diagnosis, but not in arthrogenous (degenerative TMJ disc disease). (Our note: the problem was not in the TMJ joint but likely a problem of cervical spine instability). This is something the researchers concluded as well:

“cervical muscle tenderness differentiated between TMD patients and controls and between TMD diagnoses. Specific patient and pain characteristics associated with poor outcomes in terms of cervical muscle tenderness included effects of interactions between myogenous TMD, female sex, whiplash history, comorbid body pain and headaches, and pain on opening. It can, therefore, be concluded that routine clinical examination of TMD patients should include assessment of the cervical region.”

Craniocervical muscle problems in older patients with myofascial temporomandibular pain disorders

A 2019 study from Orthopedic and Oral and Maxillofacial Surgeons in South Korea published in the journal Archives of Gerontology and Geriatrics (10) demonstrated the associations among degenerative changes in the cervical spine, head and neck postures, and myofascial pain in the craniocervical musculature in elderly with myofascial temporomandibular disorders (TMDs).

In this research:

  • A total of 120 participants (overage age about 68) were included:
    • 45 participants had no signs of orofacial or cervical pain,
    • 26 participants had myofascial TMD only and
    • 49 participants had both myofascial TMD and cervical pain.
  • Myofascial trigger points were evaluated in the temporalis, masseter, trapezius, sternocleidomastoid, sub-occipitalis, and splenius capitis muscles. Relationships among the number of trigger points, head postures, and cervical degeneration were investigated using repeated-measure analysis.

RESULTS:

  • The degenerative changes recorded in each level of the cervical spine had complex interactions with head postures. Cervical degeneration, particularly at the level of the second to the third vertebra appeared to be linked to the development of active trigger points in the masticatory and cervical muscles. The results of this study demonstrated that degenerative changes in the cervical spine were related to altered head postures and the development of active trigger points in the craniocervical musculature in the elderly with myofascial TMD.

Jaw pain, neck pain, dizziness, headache, tinnitus

A September 2023 paper in the Journal of Personalized Medicine (11) compared dry needling to manual therapy. In discussing the various results, the researchers in conclusion wrote: “Finally, it is important to remark that patients with TMDs present clinical signs and symptoms of cervical disability or dysfunction. Pain in musculoskeletal cervical structures may manifest in jaw muscles due to the connection and convergence between craniofacial and cervical afferents (sensing deep muscle pain) in the upper cervical nociceptive neurons (nerves that provide pain sensation) and trigeminocervical nucleus (where dysfunction creates jaw pain, neck pain, dizziness, headache, tinnitus, among other symptoms). The greatest reduction in the magnitude of pain in the temporomandibular joint zone may explain the reported improvements in cervical disability assessed with (the neck disability index survey) after the therapy. Our findings showed that both therapies are effective in reducing cervical disability after the full treatment.”

TMJ is a cause of dizziness

When balance is off, a person often complains of dizziness or lightheadedness. Dizziness or lightheadedness is a common symptom for those who have TMD or cervical instability. There are three well-known mechanisms by which cervicogenic dizziness occurs:

  • Irritation of the cervical sympathetic nervous system.
    • You can go way back to 1981 as evidence that this has been a known cause of dizziness. Here a paper published in the Journal of Japanese Orthopaedic Surgical Society (12) studied the effect of injury to the cervical spine, especially whiplash injury of the neck, and how it was later revealed that many patients who had sustained cervical trauma complained of, or later develop, vertigo similar to that encountered in Ménière’s syndrome. Some authors offer clinical evidence to show that vertigo results from cervical nerve root irritation which is due to hypertrophic arthritis (bone spurs causing nerve root compression or irritation) of the cervical spine and which responds to cervical traction. (Getting the neck back to its original curvature).
  • Mechanical compression or stenosis of the vertebral artery, and
  • Functional disorders in C0-C3 involve proprioceptors (the sensors that in this case tell your head where it is within space).

One that I believe is missing is cervical instability-induced vagus nerve compression.

Otolaryngologists fail to diagnose TMD as a source of the problem

A November 2023 paper in the medical journal BMC Oral Health (13) wrote: “Symptoms of temporomandibular disorders (TMD) could be present as otologic symptoms like earache and dizziness in some patients. In most cases, these symptoms are not recognized because otolaryngologists fail to diagnose TMD as a source of the problem.”

In this study, patients who were complaining of otalgia, ear fullness, tinnitus, hearing loss, and dizziness were evaluated and forty patients who had no known otologic or other primary causes to explain their symptoms were referred to the orofacial pain clinic with a possible diagnosis of TMD. If the diagnosis was confirmed by an orofacial pain specialist, a combination of TMD treatments was administered.

According to the researchers, “All patients received standard treatment protocol instructions, including a soft diet, stretching exercises, moist heat, and ice pack, correcting neck posture, and eliminating parafunctional habits.” The results showed that more than 50% of the patients reported complete or partial recovery in the second follow-up.

The study’s authors recommended that in cases with unexplained otologic symptoms, otolaryngologists should explore neck trigger points (TP) and ask about the patient’s parafunctional habits (habits related to the mouth such as bruxism or nail biting) as poor neck posture, cervical trigger points, or these parafunctional habits may be contributing to their TMJ symptoms.

One of the easiest ways to understand how TMD and upper cervical instability affect balance and various symptoms is to consider the Eustachian tube and the vagus nerve

What are we seeing in this image? Proper eustachian tube function vs. dysfunction. The proper opening of the eustachian tube requires the action of the levator veli palatine and tensor veli palatine muscles innervated by the vagus and trigeminal nerves respectively. When these muscles don’t operate optimally, fluid builds up in the middle ear potentially causing ear discomfort, fullness, pressure, pain, dizziness, and even partial or complete hearing loss.

Proper eustachian tube function vs. dysfunction. The proper opening of the eustachian tube requires action of the levator veli palatine and tensor veli palantine muscles innervated by the vagus and trigeminal nerves respectively. When these muscles don't operate optimally, fluid builds up in the middle ear potentially causing ear discomfort, fullness, pressure, pain, dizziness and even partial or complete hearing loss.

One of the eustachian tube’s functions is the ventilation of the middle ear to equilibrate air pressure in the middle ear with atmospheric pressure and drainage and clearance into the nasopharynx of secretions from within the middle ear. This eustachian tube is innervated by the vagus nerve and mandibular branch of the trigeminal nerve, both of which are affected by TMJ and upper cervical dysfunction or instability.

One of the easiest ways to understand how TMD and upper cervical instability affect balance and various symptoms is to consider the Eustachian tube. The Eustachian tube is a canal that connects the middle ear to the nasopharynx. Its job is to create equal pressure between the outside world and the middle ear. When Eustachian tube dysfunction occurs, there is a disturbing middle ear pressure to inner ear pressure relationship, causing dizziness, vertigo, and imbalance. TMD has been found to affect Eustachian tube function. The structures involved in the vestibular system are responsible for:

  • maintaining balance, posture, and the body’s orientation in space
  • regulating locomotion and other movements
  • keeping objects in visual focus as the body moves
  • controlling muscles and joints, sensation in fingertips, palms of the hand, and soles of the feet
  • adjusting heart rate and blood pressure

 The vestibular system shows the interconnectivity of body functions. Sensory input from the inner ear, sight, and proprioception (from the neck primarily but can be from other parts of the body) go to the cerebellum, which coordinates and regulates posture, movement, and balance. Some of the sensory information also goes to the brainstem and, together with the cerebellum, they figure out what to do with all this information. In order to have balance, we must have the right motor impulses and the right eye movements to make postural adjustments. There is evidence that suggests that upper cervical sensory nerves interact directly with vestibular nuclei in the midbrain to keep us upright and stable. Balance issues, especially after a neck injury point toward the missing diagnosis, cervical instability as being the cause.

Eustachian tube dysfunction is one of several mechanisms by which upper cervical instability can cause lightheadedness, dizziness, imbalance, tinnitus, and vertigo. Upper cervical instability can also produce these symptoms through compression of the vertebrobasilar artery, resistance to cerebrospinal fluid flow, dysautonomia, as well as altered proprioceptive input through mechanoreceptors.

The last is perhaps most important because the brain can only give the right instructions to the rest of the body if it gets the right sensory information. For the body to have the head perfectly balanced on the neck and for the rest of the body to balance on planet Earth, you need exact sensory information coming from the mechanoreceptors to the central nervous system. They have to function at an optimum level at all times. When there is upper cervical instability, this does not occur. Another point that needs to be made is that the upper cervical instability also makes much of the body unable to carry out the commands of the brain even if the commands are correct. So one can see again that upper cervical instability has whole body-damaging effects!

Is it eustachian tube dysfunction or TMJ dysfunction

There is a controversy surrounding the understanding of eustachian tube dysfunction and TMJ dysfunction. Doctors from the Cedars-Sinai Medical Center in Los Angeles, the University of Louisville, and Indiana University wrote in April 2020 in the medical journal Laryngoscope (14) “Symptoms of eustachian tube dysfunction (fullness, pressure and/or pain in the ears) are highly prevalent among patients with TMJD determined by patient-reported outcome measures. It is not clear if these symptoms reflect true derangement of eustachian tube function in these patients or whether there is only clinical similarity between Eustachian tube dysfunction and TMJ dysfunction. However, future research efforts may resolve this dilemma.”

Ocular Stabilization Reflexes

In discussing dizziness related to the cervical spine or TMJ, several reflexes should be addressed that give balance to the body so we don’t fall over or get symptoms such as dizziness or vertigo when upright or changing positions. Balance is provided by automatic reflexes for stabilization of the visual field (vestibulocochlear reflex, VOR) as well as for erect standing (vestibulospinal reflex, VSR) and head position (vestibulocollic reflex, VCR) so that we can have correct posture. All of these reflexes are called ocular stabilization reflexes serve to stabilize the visual image on the retina during head movements. These help us have the proper posture so we can balance and see what we are doing without falling over. When the vestibular system is not working properly, even small head movements can be accompanied by gaze instability and postural imbalance results. The vestibular system is crucial in controlling gaze, balance, and posture, and an imbalance can manifest as a dramatic, sudden onset of vertigo. The vestibulocochlear reflex (VOR) functions to stabilize gaze and ensure clear vision during everyday activities. Vestibular signals from the inner ear go to the vestibular nuclei in the medulla (brainstem), which connect to the cranial nerves that control eye movements. During head movement, the eye movement is equal and opposite to that of head movement. The vestibulospinal (VSR) reflex stabilizes the head and upright posture in relation to gravity.

The vestibulocollic reflex (VCR) serves to stabilize the head position in space. Muscles of the neck respond to input from the vestibular system to provide reflexive head movement. For example, when the head is rotated in relation to the neck, the VCR stabilizes the head position thereby stabilizing gaze direction in space. When the head moves, the vestibulocochlear reflex (VOR) tends to stabilize the image of an object in space on the retina by producing eye movement compensatory to head movement.

In all probability, you have experienced a bout of dizziness at least once in your life, but you may not have analyzed how this phenomenon occurred. Our balance is maintained thanks to the interaction between the visual, vestibular, and spinal systems. The visual system makes us aware of the position of our bodies in relation to our environment; the vestibular system detects various motions such as walking, stopping, turning, or head movements; and the spinal system makes these movements happen. When we move our heads, the fluid within the vestibular system (inner ear) is set in motion, generating an electrical impulse that is carried to our brain for interpretation. When the brain recognizes the impulse as a head movement, it signals our eyes to move in a way that will maintain clear vision during the motion. The brain also signals our muscles to ensure good balance, regardless of whether we are sitting, standing, lying down, or moving.

The vestibular systems in both inner ears must work equally well sending uninterrupted signals to the brain because otherwise one’s sense of balance will be disrupted. When this happens, a person experiences dizziness, lightheadedness, or vertigo with symptoms such as unsteadiness on their feet, feeling woozy, or having a sensation of spinning or floating. Often the person is said to have Meniere’s disease, resulting from an abnormality in the way fluid of the inner ear is regulated; however, no basis for this is ever found. Perhaps the true missing diagnosis is TMJ instability.

TMJ and Fibromyalgia

A November 2023 paper in the Journal of Oral & Facial Pain and Headache (15) evaluated the prevalence of chronic widespread pain and fibromyalgia syndrome in temporomandibular pain disorders patients and the prevalence of temporomandibular pain disorders in patients with fibromyalgia syndrome. The researchers pooled data from 19 previously published studies and found:

  • TMDs in fibromyalgia syndrome patients of 76.8%
  • Myogenous (pain from masticatory muscles) TMDs were more prevalent in fibromyalgia syndrome patients 63.1% than in disc displacement disorders 24.2%
  • 41.8% of fibromyalgia syndrome patients had comorbid inflammatory degenerative temporomandibular pain disorders.

A July 2019 paper published in the journal Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (15) previously found an association between temporomandibular pain disorders and fibromyalgia with muscle pain, temporomandibular joint pain, and muscle tenderness on palpation as the most common symptoms. Fibromyalgia can be an etiologic or aggravating factor for temporomandibular pain disorders, or it may represent a general vulnerability to pain disorders.

TMJ and Scoliosis

An August 2023 study (16) suggests a possible link between scoliosis and dental malocclusion, however, this link is still controversial. In this study, patients with suspected dental malocclusion and scoliosis were surveyed with questionnaires about their conditions. The researchers say their study’s findings: “suggest the necessity of assessing the spinal condition in patients with a diagnosed malocclusion, as well as checking for certain types of malocclusions in patients with a possible or confirmed presence of scoliosis. ” Further, they suggest dentists and orthopedists have to check, as early as possible, for the probable presence of both pathologies to avoid a severe progression which, in most cases, may require significant therapy and even surgery.”

A December 2023 study in the journal Clinical Radiology (15) investigated the relationship between temporomandibular disorders and the stomatognathic system (the system where functions of chewing, swallowing, talking, etc). Fifty patients 12-18 years old with adolescent idiopathic scoliosis and 50 healthy individuals were examined and followed. The researchers found the incidence of TMD was significantly higher in the scoliosis group compared to the control group. Among scoliosis patients, a moderate negative correlation was observed between the Cobb angle (indicative of curvature severity) and mouth opening (the more severe the spinal curve the less the mouth opening). Additionally, it was found that a 1-unit increase in joint space elastography value (a measure of soft tissue stiffness, in TMJ typically a measure of the temporomandibular joint (TMJ) disc and masseter muscle) led to a 4.81-fold higher likelihood of diagnosing disc displacement with reduction. (In other words, the stiffer the disc and muscles, the greater the likelihood of disc displacement. According to the researchers this “underscore(s) the importance of joint elastography as a valuable quantitative tool in TMD diagnosis.”)

Irritable Bowel Syndrome, gastrointestinal distress, and TMJ syndrome

In November 2020, doctors in Spain writing in the International Journal of Environmental Research and Public Health (16) sought to identify if the presence of irritable bowel syndrome was included as eligibility criteria of participants included in clinical trials investigating the effects of physical therapy in individuals with temporomandibular pain disorders (TMDs). In other words, was irritable bowel syndrome recognized as a comorbidity or condition in addition to TMJ that the patient suffered from? The reason for asking this question was that a link had been noted in previous research.

In 2014, doctors at the University of Maryland wrote: “The majority of patients with temporomandibular disorder report symptoms consistent with irritable bowel syndrome. Stress and female prevalence are common to both conditions.” (17)

In 2017 doctors writing in the World Journal of Gastroenterology (18)  investigated the prevalence and the risk of temporomandibular disorders (TMDs) in patients with irritable bowel syndrome (IBS) (including each subtype: constipation, diarrhea, and mixed) compared to the general population. Bowel syndrome patients had a more than three times greater risk of TMD compared to healthy controls. The risk of having TMD was similar in different IBS subtypes. IBS patients who also fulfilled the criteria for TMD seem to share along with chronic facial and abdominal pain a significant co-occurrence with psychiatric disorders and female preponderance.

Temporomandibular disorders and Lyme Disease

There is a great controversy in the medical literature when it comes to temporomandibular disorders and Lyme disease. The controversy is whether the patient has TMD if diagnosed with Lyme disease, or if the pain they feel in the jaw and the masticatory muscle pain is not TMD but a symptom of Lyme disease.

In my article Neck Pain and Lyme Disease: Will Treating Neck Pain Make Lyme Disease Symptoms go Away? I suggest that in the many patients we see with cervical spine instability, chronic neck pain, and neurological challenges, there is sometimes a concurrent diagnosis of Lyme Disease. It is often thought that neck pain is a symptom of Lyme Disease, and that is why the neck pain is there, for many people it is. Neck pain is also a symptom of cervical spine instability in some Lyme Disease patients, the neck problems were already there and now these neck problems are compounding their Lyme disease symptoms.

The same can be said for TMD and pain in the TMJ temporomandibular joint. TMJ pain is also a symptom of cervical spine instability as we discussed above. The challenge is is the TMD making Lyme disease worse? Is Lyme disease making TMD worse? Is it not TMD at all but the Lyme disease acting on the masticatory muscles?

A July 2019 study in the Journal of Clinical Medicine (x) attempted to determine the occurrence of temporomandibular disorders in patients with Lyme disease and to estimate the contribution of factors that may identify TMD among Lyme disease patients. The focus of identifying TMD is Lyme disease centered on Bruxism.

  • In seventy-six adult patients with Lyme disease (average age about 57 years old) and 54 healthy non-Lyme volunteers with a mean age, the two groups did not significantly differ in the frequency of disc displacement diagnoses and function-dependent pain diagnoses.
  • Lyme disease showed a significantly higher frequency of osteoarthrosis than the control group.
  • For the prediction of pain diagnoses in Lyme disease patients, age, sleep bruxism, and awake bruxism, were isolated as factors with sleep bruxism and awake bruxism much more significant. This investigation suggests that the impact of bruxism in predicting the presence of TMD pain in patients with Lyme disease is high.

In August 2021 doctors presented a case history in the journal BioMed Central Oral Health (x). In this case report, a 25-year-old woman presented extensive symptoms of temporomandibular disorder. She had extensive treatments for her temporomandibular joint and it was only after the failure of these treatments was a delayed diagnosis of Lyme disease made.

The need to differentiate between Lyme disease pain and TMD pain is illustrated by the doctor’s summary of this case: “Early interdisciplinary diagnosis of Lyme disease and early antibiotic therapy is essential to avoid misdiagnosis and unnecessary, sometimes invasive, therapies.”


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The above 1998 study was cited most recently in March 2024 paper (5) where researchers connected the occurrence of cervical spine pain as a more common problem in younger people (ages 18 – 30) with temporomandibular disorders (TMDs). The researchers noted: “In young people, this problem is rarely recognized and properly treated.”

 

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