Temporomandibular disorder (TMD)

The temporomandibular joint links the lower jaw to the skull just in front of the ear: put your fingers there and open your mouth, and you will feel the head of the joint travel forward. It works harder than any other joint in the body. When the joint itself, the disc inside it or the surrounding chewing muscles stop coping, the result is pain beside the ear, clicking, and a sense that the jaw has a mind of its own. This is called temporomandibular disorder, or TMD. It is very common, rarely dangerous, and in most people it settles with simple measures — but jaw pain has several more serious causes, and those are worth knowing about too.

What it feels like

The set of complaints is fairly recognisable:

• a dull ache in front of the ear, in the cheek, in the temple and sometimes in the ear itself, usually on one side though it can be both;
• clicking, popping or grating noises on opening and closing the mouth;
• difficulty opening the mouth wide — a big sandwich will not go in, and a dental appointment becomes hard work;
• the jaw catching now and then, needing a sideways wiggle to free it;
• headache across the temples, a blocked or ringing ear, dizziness;
• tired, tight chewing muscles on waking, and a feeling that the teeth no longer meet the way they used to.

The pain usually worsens with chewing, with long conversations, with yawning and during stretches of a stressful life. Many people go first to an ear specialist, convinced the problem is in the ear, because it refers there very convincingly. It is also worth knowing that painless clicking of the jaw is present in a great many perfectly healthy people and needs no treatment at all.

Where it comes from

It is rarely one cause; usually several add up:

• Clenching and grinding the teeth. By day, under pressure, at the wheel, in front of a screen; by night, in sleep, which people usually know nothing about until a partner mentions it or the dentist sees worn teeth. The chewing muscles work all night, and in the morning the jaw hurts.
• Stress and short sleep. This is not "all in the mind": tension goes literally into the muscles of the face and neck, and poor sleep lowers tolerance of pain.
• Overload from habits. Hours of chewing gum, biting nails and pen tops, tearing hard food with the front teeth, resting the chin on a hand.
• A displaced joint disc. The cartilage pad inside the joint slips and slots back into place, which is where the click comes from; when it stops slotting back, opening becomes limited.
• Age-related change in the joint and arthritis, including inflammatory kinds.
• Injury — a blow to the jaw or chin, a long dental appointment with the mouth held wide, intubation during an anaesthetic.
• The shape of the bite — a weaker factor than is generally assumed: plenty of people with an uneven bite never get any jaw pain.

First things first: rest the jaw

The logic of treatment is simple — take the load off the joint and the muscles and give the irritation time to settle. For most people it works.

• Soft food. For two or three weeks drop everything that needs long, hard chewing: tough meat, toast, nuts, raw apples and carrots, chewy sweets, baguettes. Cut food small and chew on both sides.
• Do not open wide. Support the chin with a hand when yawning, avoid big bites, and take breaks when singing or talking at length.
• No gum, no nails, no pen tops. This is the most common and the most underestimated overload of the lot.
• Teeth apart. At rest the lips are together, the teeth are not touching and the tongue sits against the palate. Check yourself several times a day: most people with this problem hold the jaw clenched for much of the day without noticing.
• Heat. A warm damp cloth or a hot water bottle through fabric, held in front of the ear for fifteen to twenty minutes, relaxes the muscles. If the joint is swollen and sharply painful, cold suits the first few days better: ice wrapped in a towel for about fifteen minutes.
• Self-massage. Work gently with the fingers, in small circles for a few minutes, over the muscle in the cheek and the one at the temple.
• Painkillers. Paracetamol or a medicine from the non-steroidal anti-inflammatory group, in a short course. With stomach, kidney or heart disease, or where other medicines are being taken, check the choice with a doctor or a pharmacist.

Exercises, night-time clenching and stress

Once the acute pain has settled, movement is added to the rest: a jaw held still starts to hurt in its own right. Exercises are done several times a day, slowly, to a light stretch and never through pain. For instance: rest the tip of the tongue on the palate behind the upper teeth and open and close the mouth slowly, watching that the jaw travels straight and does not veer to one side; or resist opening gently with a finger, holding the effort for a few seconds. It is best to have the routine tailored by a physiotherapist who works with jaws.

Night-time clenching is dealt with separately. The signs: a sore, tired jaw in the morning, a headache on waking, worn or sensitive teeth, tooth imprints along the edges of the tongue, a partner complaining about the grinding. Anything that improves sleep helps: a fixed bedtime, no coffee after the middle of the day, the screen well away from the bed, a calm evening. Alcohol at night makes grinding worse, not better. A dentist can make a splint — a thin custom-made guard worn over the teeth at night. It does not teach the jaw to stop clenching, but it takes the load, protects the teeth and often removes the morning pain. A splint is made from an impression; the ready-made ones sold over the counter fit worse and sometimes make matters worse too.

Stress is not a side note here but a working part of the treatment. Breathing exercises, regular physical activity, relaxation techniques and, where anxiety is long-standing, talking to a psychologist bring muscle tension down as effectively as tablets do. And if the clenching began after starting a new medicine, tell the doctor: some medicines provoke it.

Jaw pain that may not be the joint

Before treating the jaw it is worth being sure the jaw is really the problem. There are two situations in which this pain means something else entirely.

In someone over fifty, jaw pain on chewing may be temporal arteritis, also called giant cell arteritis. It is recognised by its pattern: the pain builds after half a minute or so of chewing, forces the meal to stop, and after a pause chewing is possible again. Alongside it there is usually a new headache in the temple, a scalp that is sore when combing the hair, weakness and weight loss. This is an emergency: untreated it causes sudden, irreversible loss of sight, so it needs urgent assessment — and with any disturbance of vision, immediate assessment. There is more about it on our page about giant cell arteritis.

Jaw pain can come from the heart. Angina and heart attack frequently refer to the lower jaw, the teeth, the neck and the left arm, and in some people — particularly women, older people and people with diabetes — there may be no chest pain at all. What should raise concern is pain that comes on with exertion and eases with rest, and any jaw pain accompanied by breathlessness, cold sweat, nausea, faintness or heaviness in the chest. In that situation call an ambulance at once; in Spain, Italy, Portugal, Poland and Ukraine the single European emergency number is 112. Working out whether it is "the joint or not" is not the task of that moment.

A tooth, a swelling and a jaw that will not close

Two more situations regularly mistaken for a joint problem.

Dental infection. If there is a painful tooth that reacts to heat and to tapping, the gum or cheek is swollen and a temperature has appeared, this is not TMD but an infection, and it needs a dentist the same day. A separate warning sign is swelling that grows quickly, spreads into the neck or under the tongue, and makes it hard to open the mouth, swallow or breathe. That needs an ambulance: such an infection is dangerous.

A dislocated jaw. If after a wide yawn or a shout the mouth has stayed open and will not close, the jaw is dislocated. Do not try to put it back yourself and do not let a relative attempt it: this needs a doctor, and it is relocated with a specific manoeuvre, with pain relief and muscle relaxation if required. The longer the joint stays out, the harder it becomes to reduce. Brief catching that frees itself with a small sideways movement is a different matter and belongs to the ordinary picture of TMD.

And one more reason to be seen — not urgently, but definitely: one-sided pain that keeps building week after week, numbness of the chin or lip, a lump in the jaw or neck, unexplained weight loss. These signs are uncommon but serious, and a splint is not the answer to them.

What a doctor can offer

If a few weeks of self-help have changed nothing, professionals come in, usually a dentist or a family doctor. They examine the joint and the muscles, assess how the mouth opens, check the teeth and rule out the things described above. Imaging is not always needed with a typical picture; it is arranged where arthritis, injury or something less common is suspected.

After that the options are:

• a custom-made splint, together with sorting out whatever is spoiling the sleep;
• a course with a physiotherapist: exercises, hands-on work on the muscles, sometimes equipment-based techniques;
• stronger pain relief in a short course, medicines that ease muscle spasm and, in long-standing pain, medicines that act on how pain is carried;
• psychological support, where the pain has run on a long time and anxiety is clearly feeding it;
• injections into the joint or into overworked muscles, given by a maxillofacial specialist.

Surgery is a last resort. It is discussed rarely, and only where there is a clear mechanical problem inside the joint and everything else has been tried. Something else is worth knowing: irreversible treatment aimed at the bite — grinding teeth down, fitting crowns or braces purely to cure jaw pain — is no longer recommended, because the benefit has not been shown and the teeth cannot be put back as they were.

The reassuring part is that very few people get anywhere near that. The great majority with a temporomandibular disorder recover with conservative treatment, though sometimes more slowly than one would like: the pain can quieten and return over several months, and that is a normal course rather than a sign that treatment is failing.

Online consultation

A remote appointment for jaw pain is useful above all for separating an ordinary temporomandibular disorder from the things that impersonate it. The doctor will ask how the pain behaves, whether it is tied to chewing and exertion, what is happening with the ear, the teeth, the vision and the general state of things — and will say whether this can be managed at home or needs to be seen urgently. After that the conversation turns practical: how to rearrange eating for the next few weeks, which exercises to do, what to do about night-time clenching and which dentist to see for a splint, which painkiller suits you. Follow-up works well remotely too: after two or three weeks it is clear whether the measures are helping, and if not, you can decide together who to see next.

This material is for information only and does not replace medical advice.