Leaving his GP with a prescription for antidepressants, Chris Cullen feared he would never feel like himself again. For nearly two years, he’d endured dizziness and headaches, his ears felt permanently clogged, he was also exhausted, and his mood had reached rock bottom.
His GP diagnosed depression. But Chris, a project manager, wasn’t depressed. His symptoms had a distinctly physical cause – a problem with his jaw known as temporomandibular joint dysfunction (TMJD).
However, GPs and dentists don’t always recognise the condition, leading to the assumption that it is psychological. Some treatments used to treat jaw pain – such as tooth extraction – can make it worse.
Since his problems began in February 2011, Chris, from Fulham, West London, had seen 15 specialists, including a cardiologist, a neurologist and a chiropractor, who all came up with a different diagnosis – from low blood pressure to a spinal issue. Yet none could explain all of his symptoms.
So when the 28-year-old saw his GP in March 2012, he was desperate. ‘He’d offered me antidepressants the year before, but I’d resisted,’ he says. ‘Deep down I knew my problem wasn’t depression. But after so many tests, you do start to doubt yourself, so I reluctantly agreed to take them. The irony is, by that point I probably was a bit depressed – but I felt low because of my symptoms, not the other way around.’
The temporomandibular – the technical name for the jaw joint – works like a complex hinge, which can also slide back and forth. The jawbone is held in place by muscle attached to the joint next to the ear. A cartilage disc acts as shock absorber between the jaw and skull.
Temporomandibular joint dysfunction – also called temporomandibular joint disorder – is a broad term for any problem with the joint, the muscles around it or the cartilage disc. It can cause jaw pain, difficulty opening the mouth and sometimes a clicking noise.
‘This clicking isn’t a problem in itself,’ explains Professor Andrew Eder, a specialist in restorative dentistry. ‘But it can be a sign that the different components in the jaw joint aren’t working in harmony.’
The condition affects one in five people at some point, say the NHS. A common cause is over-worked, inflamed muscles and ligaments around the jaw from chewing gum, or grinding teeth – often at night.
‘When you clench your teeth to grind them, the jaw joint can’t slide around and this puts stress on the muscles, teeth, and joint,’ explains Professor Eder. ‘A mouthguard worn at night to keep the top and bottom teeth separated can help the joint and allow the muscles to relax.’
As well as tooth grinding, the jaw joint can be pushed out of alignment by a blow to the head, poorly fitting dentures, dental treatment, biting your nails, or even by yawning or opening your mouth widely to eat.
While the problem often clears up on its own, in severe cases the cartilage can slip too far out of place, leaving bone to rub against bone, causing wear and tear.
Other conditions, such as osteo-arthritis, rheumatoid arthritis and gout flare-ups, can also cause stiffness, swelling and pain in the joint. Very rarely, TMJD may be caused by a tumour in the jawbone. The condition can cause headaches, as pain from the joint radiates to the side of the head, or because the muscles around it are in spasm. Pain can also radiate into the neck or back. Because the joint is so close to the ear, it can cause a blocked-up feeling, dizziness and tinnitus, too.
While TMJD doesn’t directly cause depression, it can become a symptom, according to Luke Cascarini, a consultant oral and maxillofacial surgeon at Guy’s Hospital, London. ‘Quite a lot of my TMJD patients are depressed, but they’re usually depressed because they’ve got chronic pain, tinnitus and dizziness, and are not sleeping well,’ he says.
Patients with chronic TMJD need orthodontic treatment or surgery, but getting the right diagnosis can be difficult, as Chris discovered.
His symptoms started with a persistent headache. Then, as well as dizziness and constant tiredness, he developed a ‘weird feeling of fullness in my ears – like when you’re on a plane and you need to pop your ears’, he recalls. ‘My GP couldn’t pin down any cause. So he referred me to a private physician, who thought it might be to do with my hormones.
‘But the only thing my blood tests showed was slightly low levels of vitamin D. I was given a supplement, but the consultant had to admit he was clutching at straws.’
Chris went on to see multiple specialists. ‘The more tests you have done, the more worried you feel. After 15 different consultants, there was no one left to see. So I went back to my GP and agreed to give antidepressants a try. I took them for a few weeks, but they made no difference.’
In desperation, Chris went online. ‘The one thing that kept coming up was TMJD. Funnily enough, this had been ruled out by the last specialist I’d seen, a neuro-otologist [a balance expert],’ he says.
Chris decided to look for a TMJD expert anyway. In April 2012, he saw specialist orthodontist Dr Patrick Grossmann, who sent him for an MRI scan.
This confirmed that both jaw joints were misaligned, the cartilage discs had slipped and there was wear and tear inside both joints. It’s thought this could have been triggered by a cycling accident Chris had in 2010, or dental work he had to fit braces to straighten his teeth.
For this kind of TMJD, special splints can be fitted to help the joint correct itself. As Dr Grossmann explains: ‘These keep the jaw joint relaxed and limit the amount of movement that can take place. This also helps recreate space for the slipped discs. Sometimes this can be enough to ease symptoms.’
Chris noticed the difference straight away. ‘Practically overnight, the fullness in my ears started to go. It was such a relief to know it wasn’t all in my mind.’
However, the splint didn’t totally clear his symptoms. Dr Grossmann suggested surgery to reposition the cartilage discs.
TMJD pain can be relieved by washing out the joint to get rid of debris that might be causing irritation, or by injecting a steroid if there’s inflammation. But this is not always a solution as the disc may not be restored to its correct position.
Chris had the operation in January 2013. Now free of symptoms, he says: ‘I’m exercising again and cycling to work. It’s given me my life back.’
So why is this treatment not commonplace? ‘There continues to be controversy and debate among professionals, which causes confusion to patients,’ says Dr Grossmann.
‘A lot of clinicians don’t accept the problem is due to disc displacement. In part, because too few patients with the condition undergo MRI scans, so clinicians are unaware of any disc displacement.
‘Many don’t believe splints can be effective either, and too often they give patients an off-the-peg plastic mouthguard, which can make symptoms worse.’
People with tinnitus or blocked ears may get sent to ear, nose and throat specialists, too, says Mr Cascarini, who adds: ‘GPs are also more switched on to depression, which may be why they assume it’s psychological.’
The key is that people raise TMJD as a possibility. Mr Cascarini says: ‘Many patients I see have been in pain a long time and can get tearful when they get a diagnosis – and hear there are ways to treat this.’