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Temporomandibular joint syndrome (or TMJ syndrome to give its most common name) is a condition associated with the jaw muscles which control chewing. The hinge joint between the skull and the lower jaw bone is a common site of pain.

Those with symptoms of TMJ syndrome commonly complain of headache or facial pain. In many cases, they have been labelled as having an”atypical facial pain’ or arthritis of the jaw joint.

Atypical facial pain simply means that the condition is not typical of the recognised physical causes of facial pain such as trigeminal neuralgia or sinusitis. But, with most, there is no evidence of arthritis in the jaw joint.

Rather they commonly and unknowingly clench their jaws and grind their teeth at night. The condition is usually seen as a consequence of day-to-day tension causing extreme muscle tension in the muscles which control chewing.

The TMJ syndrome also commonly causes pain in the ear, the side of the head, and the side of the neck on which the jaw joint is affected. This condition is sometimes confused with the severe pain that occurs in tic douloureux or trigeminal neuralgia.

Other less known effects of the TMJ syndrome include nasal stuffiness, burning of the tongue and mouth and hearing difficulties. These latter can range from clunking and grating sounds in the ears to the relative losses in hearing in the absence of any discernible hearing problem or ear wax buildup.

Many of those seen at the general pain clinic and at the specialised pain clinics at some dental hospitals which deal with mouth and face pain have previously been treated poorly, with unnecessary multiple dental procedures, ear, nose and throat procedures and sometimes neurosurgical operations.

Treatments The simplest form of treatment is the proper application of a dental night splint. This simple plastic device is inserted between the upper and lower jaws and is worn at night, and at times during the day, to prevent grinding of the teeth.

At times, muscle relaxant medications are prescribed and, for those in whom depression is thought to be playing a leading role, antidepressant medication is also prescribed. Among the more com¬monly prescribed medications for this condition are Mersyndol and Norgesic, both of which contain combinations of muscle relaxants and pain killers.

Heat treatment, such as microwave therapy, and relaxation treatment such as hypnosis or biofeedback are sometimes of benefit for this condition.

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Can doctors also play the ‘pain game’? Doctors are at least partly to blame for the public’s rampant use of drugs. Some find it all too easy to reach out for the prescription pad, encouraged by extravagant drug company advertising and ‘free’ samples and by too little time for too many patients, or by too many apparently impossibly difficult problems. Drugs to wake you in the morning. Drugs so you can keep driving when you’re exhausted. Drugs to help you sleep.Drugs to prevent pregnancy. More drugs to cure headaches or a dozen other ‘quick-fixes’. In plain terms, drugs are the easy way out for a doctor faced with a patient who keeps insisting: ‘Doctor, do something!’

The ‘easy’ way out

It may be rare in this era of ‘ Three minute medicine’ to find a doctor who is prepared to take the time to earnestly try to come to grips with a patient’s problems. Patients may also wish to avoid the issue. Or,they may simply not be able to identify the real cause of their chronic pain.

Doctors are bombarded with advertising and scientific journals extolling new drugs and treatments. Patients read about a new miracle treatment and build up the expectation that this is the answer to their problem. On the other hand, rare is the patient who hasn’t been victimised by the ‘It’s all in your head!’ game. The doctor can all too easily dismiss the problem he or she cannot or does not want to solve by simply prescribing tranquillisers. Valium is now the world’s biggest selling drug — despite it being widely recognised as causing emotional depression and even physical dependence when used for overly long periods.

Patients who ‘doctor shop’, picking up several prescriptions along the way, often take a combination of tranquillisers and pain relievers — with devastating results. Even the minor tranquillisers have well-known side-effects and problems associated with withdrawal. When used properly, as muscle relaxants or anxiety-relieving drugs, they still have a major place in medicine in general and the treatment of the patient with chronic pain in particular.

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The frequency, and intensity, of the spontaneous pain attack may increase over the years and the pain may even spread to distant areas of the body. Pain specialists are often surprised how even minor injuries may cause astonishingly severe pain.These prolonged, agonising pains inevitably force us to examine the purpose and the value of pain. First, the pain that occurs before serious injury has real survival value. It produces immediate withdrawal or some other action.

Second, the pain which prevents further injury serves as the basis for learning to avoid potentially harmful objects or situations. Third, pain due to damaged joints, abdominal infections, diseases, or serious injuries, set limits on activity and enforce inactivity and rest. This is often essential for the body’s natural recuperative and disease-fighting mechanisms to ensure recovery and survival.

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You’ll just have to learn to live with it

In many cases pain can be largely modified or reduced substantially. In some, coping skills can markedly help the person experiencing pain to get on with their lives. To simply tell a pain sufferer that they must learn to live with their pain and not support them is unforgiveable.

Make yourself feel better by just looking at someone worse off This implies that some comfort will be taken by the patient in pain by observing another’s misery. This is unlikely to help when your world is totally taken up by your own pain experience.

Medical science can cure anything

Even in the early 1990′s medicine is a long way from having all of the answers. We still have a long to go before we can totally understand and therefore control the pain of reflex sympathetic dystrophy or post-herpetic neuralgia to name but two of the most difficult of the chronic pain conditions to treat.

I won’t have to live with this for the rest of my life

In some circumstances a lifetime of pain is exactly what may have to be coped with. However, many of the management approaches described in this book can go a long way to helping those unfortunate to be in this position to cope.

My pain is my own

To some extent this, is true. However there are now many doctors and their professional colleagues who have taken a special interest in patients with chronic pain. Also much can be learned from fellow pain sufferers.

The doctors don’t give a damn

This a misconception that is simply an incorrect generalisation. As later revealed in this book many doctors simply do not have the skills or the knowledge to help you if you have chronic pain. Hopefully the new explosion of information on chronic pain which has taken place in the last ten years will correct this problem.

All I need is more powerful medicine to get some relief One of the most important principles to be stated in pain management is that analgesics or pain-killers have a very limited role to play in the management of chronic pain and are in themselves the cause of much of the problems seen in pain clinics. One of pain management’s most important shortcomings is the lack of communication of information between pain professionals themselves and with patients experiencing chronic pain. The perceived need for more understandable information about chronic pain, both for patient and professional alike, lead to this book being written.

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If an allergic patient is given a skin-prick test there will be a strong response -known as a wheal-and-flare reaction – almost immediately. This redness and itching subsides after some time, but then a different sort of reaction can set in, producing a larger, less itchy, but more painful lump. This is known as the late-phase reaction, and it is produced by the messenger substances called prostaglandins (see p28).

When a person encounters allergens in everyday life, late-phase reactions are more difficult to discern, especially if there is frequent exposure to the allergen. But such a

reaction can sometimes be observed in asthmatic patients, for example. Brief exposure to their allergen will produce an acute reaction almost immediately, followed by recovery, followed by a more insidious return of the asthma between four and 12 hours after the exposure. The late-phase reaction has usually exhausted itself by the next day.

Late-phase reactions are important, because they probably contribute substantially to the development of ‘chronic’ allergic reactions a long-term condition in which the patient is scarcely ever free of symptoms, although the severity of the symptoms may fluctuate. During late-phase reactions, the affected organ (eg the bronchi or the skin) tends to be more sensitive to non-specific irritants, so the symptoms may be sparked off again very easily, even if the allergen has been removed. A succession of late-phase reactions can easily lead to a situation where the organ is constantly over-reacting to minor irritants.

Certain drugs block late-phase reactions by preventing cell membranes from releasing the phospholipid molecules that would normally be used to make prostaglandins. The drugs that do this are

corticosteroids {eg prednisolone) which mimic the action of hormones produced by the body. The fact that corticosteroids are so useful in controlling asthmatic symptoms shows what an important role late-phase reactions can have in allergic illness.

Corticosteroids are not simply used for allergy treatment – they suppress inflammation generally because prostaglandins are widespread messengers, produced in a variety of ways. They therefore find a use in diseases such as rheumatoid arthritis where inflammation needs to be controlled.

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