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TMJ or Oromandibular Dystonia? When Symptoms Take You Down The Wrong Path

Author: Donald Tanenbaum DDS MPH - Board-Certified Orofacial Pain Specialist at New York TMJ & Orofacial Pain

Date: July 27, 2023

For some patients, symptoms suggest a temporomandibular problem, but, in reality, they are signs of a more serious medical disorder: oromandibular dystonia.

During the course of every year, patients present at our practice with symptoms that suggest a temporomandibular problem, but ultimately, they are diagnosed with an underlying medical disorder. Many of them have already had treatment, including maintaining a soft diet, taking common muscle relaxants and anti-inflammatory medications, performing jaw exercises, and using oral appliances while sleeping to address a suspicion of sleep bruxism. Unfortunately for these patients, common treatments fail, symptoms persist, and concern develops.

Their symptoms can be identical to what TMJ patients experience so it’s easy to understand why a dentist would diagnose a TMJ problem.

4 Examples From Our Practice

  1. “Michael” came to our practice seeking relief after a two-year search to solve his escalating symptoms. He said, “I can’t eat. I put food in my mouth but can’t chew it correctly because my teeth don’t want to line up. I’ve lost 20 lbs. and no longer can enjoy a meal.” He also had daily jaw muscle tension and discomfort, sporadic jaw motion restrictions, and mild jaw muscle soreness.
  2. “Sarah” told us that her jaw always felt tired, as if it had just finished a strenuous workout. The tension in her face was ever-present.
  3. “Joan” complained that her tongue no longer had room in her mouth. She said her jaw muscles felt like they were always in spasm. But what Joan was most upset about was her inability to speak clearly. As a teacher, she was very self-conscious in front of her class.
  4. “George” reported his jaw was always off to one side or the other, so his teeth never fit correctly, and he could feel them clashing while he ate. Several of his front teeth had chipped and were fixed by his dentist. His dentist said his problems were due to night tooth grinding but a nightguard did not help.

Oromandibular Dystonia – The Underlying Diagnosis

So, what was going on with these patients and six others we’ve seen since the start of 2023? They were all eventually diagnosed with oromandibular dystonia, a neurological movement disorder characterized by involuntary slow and repetitive muscle contractures that can sometimes be painful. Oromandibular dystonia affects the muscles of the jaw, lips, and tongue, altering their resting state and posture.

Early symptoms of oromandibular dystonia can be so subtle that it is not unusual for years to pass before a diagnosis is made. Dystonias are often of unknown origin (idiopathic), related to an acquired gene (genetic), or acquired due to traumas or medications.

In all cases, there seems to be an abnormality in, or damage to, the basal ganglia or other brain regions that control movement. The onset of symptoms is usually between the ages of 40 and 70 and is more common in women than men. The estimated prevalence of oromandibular dystonia varies from 0.1 to 6.9 per 100,000 people.

Symptoms That Resemble A TMJ Disorder

In the early stages, oromandibular dystonia presents like a typical TMJ problem with symptoms such as jaw tension, stiff jaw muscles, jaw muscle or joint pain, limited jaw motion, headaches in the temples and suspicions of tooth grinding and clenching.

But patients who are ultimately diagnosed with oromandibular dystonia, these additional symptoms typically also show up:

  • Repetitive, sometimes forceful involuntary movements of the lower jaw and tongue
  • Inability to bring the teeth together in a predictable way
  • Challenges with chewing
  • A sense of exhaustion and fatigue in the face and jaw muscles
  • And the most troubling symptom of all – the inability to speak properly

When a patient’s jaw-closing muscles are in spasm, their teeth come together in awkward and frequent patterns and cause tooth collisions. Tooth collisions lead to fractured cusps and exaggerated wear patterns on teeth, even when compared to the typical bruxing patient.

Diagnosis Based On History & Symptoms

In our practice, the diagnosis of oromandibular dystonia is based on the history reported (often along with failed TMJ treatment) and the description of ongoing and unrelenting symptoms in the oromandibular region. There are times when a patient arrives, and we can see involuntary jaw motions, difficulty bringing teeth together, and speech changes. Most of these patients are miserable and have been searching for answers for several years.

Treatment For Oromandibular Dystonia

  • Neuromodulator (Botulinum) Injections: Xeomen and/or BOTOX® can be effective for oromandibular dystonia. Although relief is temporary and must be repeated at intervals of 3-4 months, injections in the masseter, temporalis, and lateral pterygoid muscles can reduce the strength of jaw muscle contracture, which eases the force of tooth clenching and grinding during the daytime hours and improve jaw motion restrictions.

    The lateral pterygoid injections must be done under fluoroscopic guidance to be most effective. Over time these injections may not work as well as they did initially, however. Unfortunately, when dystonia influences the tongue and alters speech, the benefit of these injections is not as profound.

  • Medications: There are only a few medications that can help manage symptoms. These medications are designed to influence the neurotransmitters that influence muscle contracture and spasm. They are often used in tandem with neuromodulator injections. Sadly, no medications exist that can prevent dystonia or slow its progression.
  • Other Treatment Options: Physical and occupational therapy are helpful management tools. The use of oral appliances has been cited in the literature to provide moments of relief, but results are anecdotal and there are no studies to support this direction of care. When all else fails, a select few brain and nerve root surgeries are available.

Conclusion

Michael, Sarah, Joan, and George continue injections and medications, which have provided them with some welcome relief. It is my hope that this newsletter will help dentists make an earlier diagnosis when this puzzling problem presents at their offices.

Your thoughts are welcome.

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