Your teeth and jaws could be causing you other physical problems

My friend Anja has been through quite the medical odyssey. For eight years, she was plagued by dizziness, crippling neck tension and radiating facial pain – a diagnostic ordeal similarly long for people with endometriosis or chronic pain related to trigger points.

Juggling a full-time job with being a mum, everyday life proved almost unmanageable. But neither ear, nose and throat specialists, nor orthopaedists, osteopaths or neurologists knew what to do. Cortisone injections, insoles, physiotherapy and massages were either no use, or only helped temporarily. When tinnitus was thrown into the mix, Anja was at her wits’ end and sought advice from a psychologist.

The stress-reduction tips her therapist gave her helped. At least for a few months. Then, the symptoms returned. Buried in Anja’s misfortune, however, was a nugget of good luck. When one of her tooth fillings came loose, she went to see a new dentist. Anja was initially surprised when, instead of simply replacing the filling, the dentist starting palpating her jaw and asking her all sorts of questions. Including questions about the very symptoms that had plagued her for so long.

The verdict? An hour later, Anja had not just a new filling, but an eye-opening diagnosis that explained her long-standing problems. Craniomandibular dysfunction, or CMD for short. You can read about other causes of diffuse tooth or facial pain in this article.

What is craniomandibular dysfunction?

Dentists use the umbrella term craniomandibular dysfunction to describe various disorders affecting the chewing apparatus. It’s derived from the words cranium (skull) and mandible (jaw). As the University Hospital Zurich (USZ) describes (in German): «Malfunctions occur between the skull and the upper and lower jaw. The temporomandibular joints and the masticatory and neck muscles are also involved.»

Dr Theobald Saxer, CMD expert and former dentist from Innsbruck, explains this in more detail: «The upper jaw is connected to the skull in a rigid manner. The lower jaw, on the other hand, hangs relatively loosely from the skull like a swing, held only by delicate muscles and a hinge joint. In its ideal state, this 'swing' is completely relaxed and is referred to as a resting position. When you bite down on something, the position is referred to as the «habitual bite» or «bite of convenience». If everything’s functioning normally, this mechanism works smoothly. But missing teeth, poorly fitting dentures, fillings that are too high or too low, faulty orthodontic treatment or teeth worn down by night-time grinding can disrupt this balance.»

Sometimes, genetics can cause malformed teeth. Not only that, but functional disorders of the pelvis or spine can also affect the position of the teeth and temporomandibular joint. CMD also has sub-classifications depending on its cause. Some disorders occur in tandem with CMD, creating a situation where both syndromes reinforce one another:

• Disorders in the mastication and neck muscles that cause pain when chewing or even chronic pain.
• Joint changes caused by wear and tear or diseases such as osteoarthritis.
• Symptoms triggered because the cartilage disc in the temporomandibular joint is incorrectly positioned or restricted in its mobility.

The result, however, is always the same, «The bite is altered, resulting in muscle tension,» says Saxer. This is because the jaw, face and head muscles tense up to compensate for the misaligned teeth. The potential consequence of this? CMD.

Sufferers often experience very unpleasant symptoms, from cracking noises in the jaw joint, to difficulty opening their mouth, to pain in numerous areas of the body.

When your teeth make you ill

Essentially, Anja’s teeth had made her ill. Like around one third of people, she grinds her teeth in her sleep – a phenomenon known in medical circles as bruxism. Anja’s bruxism is most serious when she’s under stress. Over the years, her night-time teeth-grinding has taken its toll. Anja’s teeth had become so abraded that her upper and lower jaws no longer met properly when she chewed. Her body automatically compensated for this misalignment, triggering tension pain in her face and neck before ultimately leading to dizziness, tinnitus and other symptoms.

At least 20 per cent of the population is affected by CMD

CMD may be an unknown or little-known disorder, but the condition is widespread. According to the Society for Dental Health, Function and Aesthetics (Gesellschaft für Zahngesundheit, Funktion und Ästhetik GZFA), roughly 20 per cent of the population suffers from CMD that requires treatment (website in German). «In the literature, the frequency of CMD is even stated to be around 40 per cent or higher,» says the University Hospital Zurich (USZ).

Not everybody whose teeth and jaw joints are out of balance experience unpleasant symptoms. Around 20 per cent of women and 60 per cent of men are symptom-free, despite their abraded teeth. Those who do experience them (women are affected more frequently and more severely than men, while young people are more commonly affected than older people), however, often have serious, painful symptoms such as headaches, back and shoulder pain, migraines, muscle tension or difficulty swallowing.

Other common symptoms of CMD are making noises while chewing, inflammation of the jaw joint, periodontal disease, facial pain and neuralgia (nerve pain), sore throat accompanied by hoarseness and tightness, twitchiness in the eyes and sensitivity to light, dizziness, balance problems, ringing in the ears and even tinnitus and hearing loss. Extreme tiredness and a depressive mood can also be traced back to CMD.

A laborious search for the cause

With extremely varied, complex symptoms and pain manifesting itself in both the jaw area and various parts of the body, it’s not easy for dentists to diagnose CMD. ENTs find it particularly tough. «We can assume that around a third of all supposed ENT symptoms actually originate from the cervical spine and half of these patients also suffer from CMD,» says Dr Manfred Hülse, who examined the issue for many years at Mannheim University Hospital.

To make matters even more complicated, many of the symptoms, such as back pain or headaches, don’t initially point to misalignment of the teeth. Instead, they indicate a number of other conditions.

The first step for doctors in identifying CMD is to do a detailed diagnostic consultation. «You’re asked about your medical history, your symptoms and their severity, things that increase their severity, whether you grind your teeth and whether you’re under a lot of stress,» Anja says, recalling her own experience. This is usually followed up by a functional analysis of the teeth, jaw joints and chewing muscles. The doctor palpates the jaw and head muscles with their fingertips, also checking whether the mouth can be opened wide enough without difficulty (usually three fingers wide).

Specialists also have various technical diagnostic methods at their disposal. At the USZ, these include X-ray, MRI and computer tomography, which can reveal anomalies, functional disorders, inflammation or wear. They also have a chewing simulator. «The device simulates the individual points of contact between teeth (occlusion) and movements of the temporomandibular joints. It involves the use of plaster models of the upper and lower jaw that have been designed in advance to fit precisely. This means we can avoid the patient’s muscle tension and reflexes creating a false picture,» says the USZ.

Rainer Schöttl, author of the self-help book «CMD: Kein Schicksal!» (English translation: CMD: it’s not a given! (website in German) adds: «A full-body static examination also helps to identify postural problems. This is because issues in the area of the bite spread like vibrations. These 'bad vibrations' hit the spine and can affect a person’s entire posture.»

Good chances of treatment for CMD

For many sufferers, the road to diagnosis is often long and difficult. And it’s a journey that takes them to doctors’ offices from various specialities. Once the diagnosis has been established, however, CMD is treatable. With a little patience and perseverance, you can often completely rid yourself of the symptoms forever – usually without surgery (website in German).

These days, there are numerous dentists specialising in CMD in Germany (website in German). Unfortunately, there’s no directory listing Switzerland-based specialists. If this is where you’re looking for a CMD dentist, Rainer Schöttl advises: «It’s best to call them and ask them about their approach. If they involve other health professionals in the treatment process, pay attention to the link between jaw, head and body posture and determine the bite position with the body upright, you’re headed in the right direction. My advice is to find a doctor who adapts their techniques to the patient, not the other way around.»

Personalised treatment

The exact course of treatment for CMD depends on the cause. After seeing a dentist first, it may be necessary to involve other specialists from a variety of fields, from physiotherapists to ENTs. Anja, for example, has started physiotherapy in addition to splint therapy (she wears a dental splint at night to prevent her teeth from grinding). An injection of botulinum into her chewing muscles has also improved her bruxism, which she describes as «a blessing, even though my insurance doesn’t cover it». During the day, she gives herself regular massages and does exercises to relieve tension in her jaw, using videos as a guide (video in German).

In addition to her misaligned teeth, her mental health also has a major impact on her teeth-grinding. As a result, she goes to psychotherapy and meditates regularly to reduce stress.

People who’re under pressure in their everyday or family life, in their relationship or at work often react by grinding their teeth in their sleep at night. According to the USZ, some sufferers even do this during the day. As the saying goes, «gritting their teeth» helps them to get through tense situations and cope with negative emotions. CMD develop as a result or, if the symptoms are already present, they can become even more severe and ultimately chronic.

Consider CMD as a cause if you’re experiencing pain elsewhere

Anja’s advice? «If you’re having pain or discomfort anywhere in your body, think about your teeth as a possible cause and talk to your doctor about CMD.» Nowadays, Rainer Schlöttl says, this is taken increasingly seriously. «People are becoming more and more aware of CMD – not only in dentistry, but also in other disciplines. Today, many people recognise the interconnectedness of individual systems within our bodies.»