TM dislocation that's "upside-down" ??

[Unhinged]

I've had bad pain in my jaw for almost a year, and have had multiple visits with my primary doctor, 3 dentists, an ENT and a neurologist. The pain feels like a severe ache in my gums that is usually seated in my right lower jaw, but radiates to all 4 corners by the end of the day, and there is some newly developing tingling and numbness in my teeth, face, jaw, tongue and lips, and is gets much worse as the day wears on. I have no problems with opening/closing my mouth and I have full range of motion. It's all about pain.

The neurologist ordered an MRI of my brain and TM joints and just left a message that my jaw is dislocated, but the MRI shows it's better when it's open and worse when it's closed, and it's "upsode down" and should be the other way around. He said he was surprised the ENT didn't catch it on my visit with them, and I need to take my films back there for the ENT to figure it out. I'm so tired of specialists and being in pain.

My primary doctor has prescribed narcotics, anti-inflammtories, prednisone, and night guards; none of them have worked.

I had a gastric bypass 4 years ago, followed by a face and neck lift a year later. I have no major health problems. I take Prilosec for GERD. I have taken atenolol for years for some benign heart arrhythmias, and I have taken Ambien for almost 4 years for chronic insomnia.

The only time I am ever pain-free is within minutes of taking the Ambien until I wake up ,and when I chew gum in the evening when the pain is at its worse (I never chewed gum before the pain started, and I know it traditionally is supposed to aggravate jaw pain, but in my case it helps--I guess it's all part of the "upside-down" thing.).

So, does anyone have any knowledge or experience with TM joint disorder that doesn't behave like it should? I can't even figure out the specialist I need to go to. HELP!

[Felsen]

Unhinged!

I'd like to help with the disk issue in your TMJ. Could you please write exacely what the MRI report of your TMJ says. Word for word.

[Unhinged]

Unfortunately, I don't have the written report yet; just a brief verbal report from the neurologist (who honestly seems fairly clueless). I spoke with him again this morning; he reiterated again that on the MRI, the joint dislocates when it is closed and re-locates when it's open, which he says is highly unusual (he mentioned something about a "snake pattern"--just the visual I need right now). At first he said I needed an ENT, and when I asked gently about an oral surgeon instead for jaw problems, he said, "oh, yeah, I guess you need to check with an oral surgeon." Man.

I will be picking up the hard copy of the MRI and report tomorrow, and have made an appointment with an MD who is an oral surgeon/TMJ specialist at a major university for two weeks from now. I sure hope I can cut to the chase at that point. In the meantime, any additional constructive insight that doesn't involve graphics of snakes would be appreciated.

[Felsen]

You need to see a specialist in gnathology. An ordinary dentist or an ENT doctor don’t usually know too much about TMJ problems. So this guy with whom you have an appointment in two weeks, might be a good choice (the specialty educations for dentists differ from country to country, in some countries the oral surgeons take care of the TMJ problems in other countries they have specialists in gnathology).

Now, I’ll try to explain what the MRI report of your TMJ probably says. The TMJ is the joint between the jaw and the base of the skull. Inside the joint there is a disk (like in the knees). This disk is like a little cap on top of the mandibular process of the jaw. Now, the TMJ is a complicated joint, as the mandibular process together with the disk moves forward on opening and back on closing. In a normal, healthy joint the disk follows the mandibular process during opening and closing. During the movement, both opening and closing, the disk can pop out of its place and pop back. This usually creates a sound, which sometimes can be rather loud. The most common disk displacement is such, that the disk is displaced in closed position and pops back in place when you open the jaw. This displacement is most often anterior, which means that the disk is in front of the mandibular process in closed position. Therefore it’s called anterior disk displacement (ADD).

This sounds rather dramatic, but it’s usually not. About 10% of the population has ADD, without other symptoms other than the sound. I am one of them. In rare cases this creates pain. The treatment is to relieve the pressure on the joint, ie with an acrylic splint. It usually is contraindicated to chew gum, but I advise you to do that, if it relieves the pain. It’s important to relieve the pain, to prevent a chronic pain condition.

Don’t hesitate to write what the MRI report says. I’d love to help. Good luck, Unhinged!

[Unhinged]

Thanks for your help, Felson. I'm still confused about what's causing my "dislocation." Is it clenching that requires a night splight and stess reduction techniques, or was it something like a big yawn or vomiting episode (sorry to be gross--I've had a gastric bypass and early on worshiping the porcelain god was pretty common) that requires manipulation of the jaw to pop it back into place? My neurologist was so maddening with the lack of information he would give me; he just really didn't want to be bothered.

My appointment is with a TMJ specialist (a DDS/MD on staff with the department of oral and maxillofacial surgery at Emory University). I'm not leaving his office until I have a diagnosis and plan of treatment.

If I get access to the MRI before then, I'll try to relay what it says.

Thanks again.

[Unhinged]

Don’t hesitate to write what the MRI report says. I’d love to help. Good luck, Unhinged!

Greetings again, Felsen! I got the MRI. Do you know what any of it means in practical terms (is it a serious type of dislocation..am I looking at night splints or surgery??)


Findings: There is a bilateral symmetric pattern of the temporomandibular joints with anterior subluxation/dislocation of the TMJ disc on both sides in closed position with reduction of the disc position on opening. On opening, there is normal translation of the condyle from the glenoid. I do not see any secondary arthritic changes in the condyle or the glenoid of the temporomandibular joint on either side. No joint effusions are identified. Coronal images show that the TMJ discs also show mild medial subluxation.


Impression: Bilateral symmetric pattern of anteromedial dislocation/subluxation of the TMJ discs in closed-mouth position wtih reduction of the disc position on opening. No secondary arthropathy changes. Normal condylar motion.

[Felsen]

Unhinged,

I've read the report and everything is clear. But it's late here in Europe, so I'll get back to you tomorrow, OK?

Good night!

[Felsen]

By the way, I understand now the referral to snakes!

[Felsen]

This was a meticulous radiologist – she/he hasn’t missed one detail. It is as I suspected, except it’s bilateral, you have the same condition in both your TMJs, which is not all together uncommon. So, what the report says is that you have a symmetrical dislocation of both your disks when biting together. On opening both disks pop back in place. The dislocation is also a little sideways – that’s why your dentist (or was it the neurologist?) was speaking of snakes.

The report also says that there is no liquid in the joint space, which means there is no active inflammation, which is good. Also, the dislocated disks are no hindrance to joint movement, which is good also – you can manage a double whopper (I can’t). There are no arthritis signs (no inflammation) and no arthrosis signs (no wear).

It might be so that vomiting has upset your disks a little, but most of all I think that grinding or clenching teeth, especially during sleep, might have contributed. Plus anatomical predisposition. When you lie down, the jaw tends to slide backwards a little, and if you apply pressure on the joint by grinding, the disks will be easily pushed forward and popped out of place.

Any surgery is out of the question. To suture the disk back in place has proved useless. The forces inside a TMJ are so big, it won’t last. There is no need taking out the disks, they are not blocking any movement. Plus you should always avoid surgery of joints. There is no ordinary blood circulation in a joint, which makes it very vulnerable to infections.

In conclusion, I am not convinced that the ADD (anterior disk displacement) is the reason for your pain. Also I have never seen a patient being able to chew gum, while having TMJ problems. Have the dentists said anything about grinding teeth? Are there signs on your teeth of grinding? You say that the pain starts on your lower left side. Have you had any root canal treatment in that area? Any big fillings there?

[Unhinged]

Thanks for all your input and research, Felsen. I managed to beg my way into the oral surgeon today, and after a very thorough history and exam, was emphatically told that the MRI was a "red herring" and I absolutely do not have any kind of TMJ disorder. He really feels it is most probably atypical trigeminal neuralgia, and I've agreed to start on carbamazapine for a while to rule TN in or out (just the thought of brain drugs makes me depressed, but I need to change my attitude).

Your thoughts on my symptoms and MRI were dead-on. I don't know your background, but you're a great diagnostician!