Hey everyone! Wow it is wonderful to be back and, although I am missing my littles, I’m pumped to be back in the clinic seeing all of your smiling eyes (since that is most of what I’m seeing due to wearing masks these days).

But I am happy that I do get to see some of your smiling faces in their entirety! Upon returning to work from my maternity leave I have been seeing a number of you that have been dealing with temporomandibular joint (TMJ), aka jaw joint, issues. So some of you have been getting to unmask for me (only if you feel comfortable to do so) so that we can work together to settle those jaws down.

Many of the TMJ issues that I am currently seeing are related to muscular tension in the current climate. Tension has long been a cause of TMJ issues related to stress in life that results in holding tension in muscles surrounding the jaw, and sometimes clenching and grinding. Mask use has been recommended by the World Health Organization (WHO) and Centre of Disease Control (CDC) as part of the strategy to reduce the transmission of Covid-19 (1, 2, 3). Muscular tension around the jaw occurs with and without the use of masks but, for those of us that are wearing masks more these days, we are noticing some added tension.

Here are a few tips that you can use if you are having jaw tension with more regular mask use:

1. Ensure that your mask fits well. If a mask does not fit well it will not stay in place and you may find that you are opening your mouth and wiggling your jaw side to side frequently to keep it in place. Try to find a mask that allows it to be fitted over the nose or cheek bones through the contour of the mask or through a flexible wire.
2. Breathe through your nose whenever possible. Breathing with your mouth open results in the muscles of your jaw having to work harder to maintain your mouth staying open for longer periods of time and they miss out on resting when your mouth is closed.
3. If you are having issues with tension, try the following exercises: Controlled opening and self-release of masseter can be quite helpful in settling down tension. Some of you may have seen the video that I posted while I was on mat leave that addresses these key exercises that you can do to keep your jaw healthy:https://www.youtube.com/watch?time_continue=5&v=BoFesGoRi98&feature=emb_logo
   
   

For more information on dealing with persistent jaw issues please do not hesitate to contact me at the clinic!
 
~ Kristyn Froc, Physiotherapist
 
References:

1. COVID-19: How much protection do face masks offer?https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-mask/art-20485449. July 17, 2020.
2. Q&A: Masks and Covid-19. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-and-masks. Accessed August 17, 2020.
3. Considerations for Wearing Masks: Help Slow the Spread of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html. Accessed August 17, 2020.

The Trigeminocervical Complex (TCC) refers to the relationship between the upper neck, TMJ (Jaw), and trigeminal nerve, which can be associated with a wide range of conditions that affect the neck, face, and head. 

The first two joints in the neck are uniquely shaped compared to the rest of the cervical spine. They demonstrate a different set of movement patterns, have their own special muscles to produce those movements, and enjoy special connections to the nervous system that the rest of the surrounding tissues do not have. In particular, these joints connect to a cluster of nerve tissue that joins a number of areas in the face and skull. The jaw joint also shares a neighbourly relationship with some of this nerve tissue and can be involved in much the same way as the upper neck. 

What this means is that pressure, temperature, or other stimulus of these muscle or joint tissues can contribute to the overall signal being sent to our brain and the nerves of our skull and face. In this way, the muscles and joints in the upper neck and jaw can contribute to the average tension headache as well as the more complex association for migraine and other painful conditions involving the face. People who are experiencing headache complaints will also typically demonstrate increased sensitivity in these areas.

At a physiological level, all of our sensation is at some point electrical signals carried by our nerve tissue. The mechanical forces and feelings of the upper neck and jaw can amplify the signal of nearby nerves. If this amount of electrical signal is above a certain threshold in the body, it has the potential to produce feelings of tension, pain, numbness, tingling, pins & needles, tinnitus (ringing in the ears), headache, and more. 

If the nerves are particularly irritated, the presentation can include congestion of the sinuses, watering of the eyes, and irritability of the eyelids. Some more unusual symptoms that can be attributed to this area include bulging of the eyes, running sinuses, a sense of fullness in the ears, a feeling of tightness in the throat, and a general flushing of the skin in the neck and face. 

Assessment and treatment of conditions that affect the Trigeminocervical Complex and surrounding tissues can often be complex and require multiple perspectives and professionals to develop a satisfactory program. Family Physicians, Specialists such as Ear-Nose-Throat (ENT) Physicians, Audiologists, Neurologists, and Physical therapists often work together to manage all aspects of the presentation. 

While not all conditions in this area will have a mechanical relationship, as there are several diseases and medical conditions which can be a root cause as well, it can still be of value to look at conservative and non-invasive medical treatment before moving on to more investigations and tests. 

With appropriate management and restoration of the mechanical features in these areas, including hands on treatment and therapeutic exercise prescription, the overall stress on the tissues and nervous system can typically be reduced. 
If there are any questions or comments regarding this information, please feel free to comment here or reach out to our office.

-Trent, PT

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References

• Pressure pain thresholds over the cranio-cervical region in headache: a systematic review and meta-analysis. Castien et al. The Journal of Headache and Pain (2018) 19:9
• Understanding Cervicogenic Headache. Chua, N., Suijlekom, H., Wilder-Smith, O., Vissers, K. Anesthesiology and pain medicine. Feb 2012.  
• Cluster Headache: Epidemiology, Pathophysiology, Clinical Features, and Diagnosis. Wei, D., Ong, J., Goadsby, P. Annals of Indian Academy of Neurology. April 2018. 
• Head pain referral during examination of the neck in migraine and tension-type headache. Watson DH., Drummond PD. Headache. Sept 2012. 

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Tinnitus is defined as the perception of sound without the accompanying external stimulus.  
Tinnitus, or ringing in the ears, affects a significant amount of the population at one time or another in their lives. While it is normal for someone to experience intermittent episodes of buzzing, ringing, or tonal sounds in the ear from time to time, some people experience a condition which is much more persistent and sometimes more bothersome. Prevalence is estimated between 5-42% of the population.  

The condition itself does not have one root cause or pathology associated with it. It can be caused by noise trauma, physical trauma, disease, aging, and as a side-effect of some medications. A number of different structures and conditions can contribute to the presentation and the symptoms that an individual experiences. This can include cardiovascular, neurological, mechanical, and inflammatory disease states. These factors will produce a sensitivity in the nervous system, leading to changes in the brain that can produce the phantom sound or make it increasingly difficult to shift our attention elsewhere.  

From a cardiovascular perspective, an increase in blood pressure can sometimes result in the ability to hear a thudding or pounding, drum-beat like sound. This can occur unilaterally or bilaterally. This can also be the result of inappropriate formation of small blood vessels in the inner ear and surrounding tissues which does not allow blood to flow through them smoothly in all situations. Anything that is of a vascular nature will require assessment and investigations as recommended by the appropriate physician and/or specialist and is outside the scope of physical therapy.  

From an inflammatory basis, a number of structures in the face, head, and ear can contribute to the perception of sound if they become irritated or sensitive. This include various nerves, the sinuses, eustachian tubes, and even the middle ear bones that conduct sound to the eardrum. The eardrum itself can be a source of irritation if it becomes inflamed or scarred as well. The treatment for this typically is medical in nature to try and reduce swelling/inflammation in the specific tissues.
 
The neurological mechanism is the most common pathway that relates to idiopathic tinnitus. Idiopathic referring to an onset of symptoms with no known injury or mechanism. This can be due to sensitization of the peripheral nervous system, central nervous system, or a combination of the two. This is typically treated through a combination of medication, education, and stress-reduction strategies.  

Mechanically, the upper cervical spine and jaw joints can contribute to a presentation of tinnitus in some cases through their connection into a cluster of nerves referred to as the trigeminocervical complex. Since the trigeminal nerve has connections to the other cranial nerves, overwhelming stimulus of these pathways can contribute to the intensity and frequency of symptom presentation. On the bright side, appropriate mechanical treatment and education surrounding these tissues can sometimes provide improvement in the tinnitus symptoms that are experienced. Not everyone has a mechanical presentation, but since treatment and therapy are non-invasive, it can be worthwhile to consider assessment by a trained healthcare practitioner.  

Another useful avenue of assessment for those suffering from tinnitus is a comprehensive hearing assessment through an Audiologist. This will assist with understanding the unique features of a patient’s presentation and help other practitioners determine an appropriate course of action. Audiologists also have the ability to treat some aspects of tinnitus with assistive devices that can create white noise, amplify normal hearing, and try to retrain the brain/nervous system to ignore the tinnitus itself.  

One of the most important things to note regarding tinnitus is that the amount of distress or the perceived volume of the sound does not relate to the severity of the condition. Louder tinnitus does not mean that someone is at greater risk of harm or injury/disease.  

~ Trent, PT

 References: 
Somatosensory tinnitus: Current evidence and future perspectives. Ralli, M. et al. Journal of International Medical Research. 2017.  

Maladaptive plasticity in tinnitus - triggers, mechanisms and treatment. Shore, S., Roberts, L., Langguth B. Nat Rev Neurol. 2016. 
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Current insights in noise-induced hearing loss: a literature review of the underlying mechanism, pathophysiology, asymmetry, and management options. Le, T., Straatman, L., Lea, J., Westerberg, B. Journal of Otolaryngology - Head & Neck Surgery. 2017.
 

Today I was at the dentist for both my kids and for myself. And holy smokes, my 3-year-old was talking a mile a minute! He was very excited to tell the dentist how he is brushing his teeth every day. Talking is just one of the many activities that the jaw has to be able to do. Talk, chew, open up for a yawn, and smile, to name a few things. And these are some of the things that my patients have told me their jaw pain is interfering with.

Want to know something else that is interesting? The jaw is also involved with trying to handle our stress. Sometimes, when we sleep and even when we are awake, we can clench our jaw or grind our teeth. We hold tension here either temporarily or prolonged in response to stress, frustration or simply out of habit. So when I got to have the discussion with the dentist and dental hygienist that I needed to think about getting a night guard to protect my mouth due to signs of clenching I wasn’t surprised. Generally I feel like I manage my daily stress well, but sometimes I wake up in the mornings feeling like I have to move my jaw around to loosen it up. I also catch myself feeling a little more tense when I am rushing to get the kids out the door or things of that nature (I am sure I am not the only one to feel this way sometimes).

When we clench or grind, even without meaning to, there are a few things that can happen. Apart from possible wear on our teeth and gums (can you believe that you can cause gum recession or tooth fracture by clenching and grinding?!), there is also joint irritation and muscular overuse and imbalance that can occur around the jaw, which can lead to local and referred jaw pain. What does that mean? Jaw pain can feel like an ear ache since your joints are located just beside your ears. It can also feel like a tooth ache because pain from the jaw can refer to your teeth. It may also present with a headache or ringing in the ears due to muscular tension or joint pain. Lack of muscular coordination and control can lead to muscular strain and joint irritation. They begin to have trouble with things like opening, chewing, and talking which usually brings them to their dentist or their doctor, and then to me, because they are just not sure about where to go and they are a little afraid of what treatment entails when they are already having pain and difficulty with such important things that they have to do multiple times per day.

So let me talk about assessment and treatment for a moment. When I am looking at someone’s jaw, I want to know their history. I am talking more about clenching and grinding above, but sometimes there are other things that can lead to jaw pain. After discussing more about what brought them in to see me, I look at how the neck moves and how the nervous system is functioning through reflexes and cranial nerve testing. I then get into looking at the jaw. I look at how a person is opening and closing, other movements that their jaw can do, and how irritable their jaw appears to be. With many people I am also able to assess how the joints, ligaments and muscles are functioning by feeling inside of the mouth and “wiggling” the jaw around. How I approach assessment and treatment with people depends on the degree of irritability of their jaw, their goals for treatment, and what they are doing in their lives. Are they a musician? A teacher? A student? Retired? What is their dental and neck history? All of these things are important for me to know to effectively treat someone’s jaw.

So, if you are having some jaw pain, clenching or grinding during the day and/or night and issues with jaw muscle coordination may be playing a role. Paying a visit to myself or Trent can help to set you in the right direction. Feel free to give me a call if you have any questions about what may be going on with your jaw and what physiotherapy can do to help.

~ Kristyn, PT

Hello all,

My name is Kristyn and I am a physiotherapist. This is my VERY FIRST blog post ever so here we go…

Let’s talk about something that I have treated frequently over the past few years– the TMJ. “What is the TMJ” you ask? TMJ stands for temporomandibular joint. They are your two jaw joints and you can feel them just in front of your ear openings while you open and close your mouth. When I tell people that it is a part of the body that I treat they are often surprised that a physiotherapist can treat the jaw and they often tell me that they currently have issues or have had issues in the past with their TMJs.

Let’s talk about common issues or symptoms associated with the jaw. Most commonly, people come to me with jaw pain that is causing headaches and limiting opening. Frequently their jaw swings to one side and can click with either opening or closing. They often tell me that they clench or grind at night, and generally hold tension in their jaw. They also say that it feels like their teeth aren’t fitting together and it feels like their bite is “off”. Sometimes they tell me that they have ringing in their ears as well. And sometimes their dentist notices signs of wear in the teeth or gums due to clenching and grinding and sends them my way when they can’t keep their mouth open for dental procedures.

All of these things are limiting in life when someone with jaw issues is having pain from headaches due to muscular tension or imbalance, having discomfort when taking a large bite of food or when they are chewing something chewy like a steak, when their ears are ringing or they are having ear pain related to the jaw, or if they are having pain while talking, singing, or playing an instrument.

Some of the common causes of TMJ issues include:
·         Tension due to clenching, grinding, or holding tension during the day or the night
·          Hyper or hypomobility (extra movement or reduced movement) of one or both joints.
·         Joint issues due to degeneration or disc entrapment/derangement
·         Trauma to the jaw

People often discuss their jaw issues with their dentist, who is able to offer them the option of a mouthguard to protect the teeth (yes, I have seen several people who have cracked their own teeth due to clenching and grinding). A mouthguard is a plastic device that is designed to protect the teeth from wear caused by clenching and grinding at night, during the day or with impact sports. It also protects the TMJs from compression. I enjoy working with dentists to assist mutual clients with the recovery of their jaw health. I also screen my clients to ensure that they are a good candidate for physiotherapy and I will refer back to a dentist or physician if that is what is required.

Something that may surprise you is that the jaw joints and their function are closely connected with the neck! Neck issues can result in weakening or reduced coordination of the jaw muscles which can result in dysfunction. The neck provides the core foundation on which the jaw moves. Therefore, when I am treating someone’s jaw, I almost always have a look at neck mobility and function. This could be a whole other blog topic…
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If you are experiencing issues with your jaw joints we would love to help you with your recovery and restoration of jaw control and mobility. If you have any questions about how you may benefit from physiotherapy for your jaw, do not hesitate to give me a call.
 
-          Kristyn, PT
 
References
·         Wright EF, North SL. Management and Treatment of Temporomandibular Disorders: A Clinical Perspective. J Man Manip Ther. 2009; 17(4): 247–254.
·         Mota LAA et al. Signs and Symptoms Associated to Otalgia in Temporomandibular Disorder. International Archines of Otorhinolaryngology. 2007;11(4):411-415.
·         Rocabado M, Johnston Jr. BE, Blakney MG. Physical Therapy and Dentistry: An Overview. Journal of Craniomandibular Practice. 1982;1(1)46-49.