TMJ and Whiplash: The Craniocervical ConnectionTMJ is a recognized symptom of whiplash injuries; as far back as 1965, researchers have realized that many whiplash patients have TMJ pain and dysfunction.
The source of this pain is a more controversial issue. For many years researchers speculated that there must be a "mandibular whiplash" at the root of TMJ injury; this theory was based on the premise that the rapid whiplash motion caused the jaw to open forcefully, resulting in strain to the temporomandibular joint. This theory of mandibular whiplash has been studied in live occupant collision testing, however, and there is little or no evidence that the jaw experiences abnormal forces during low speed crashes. (Jaw forces have not been studied in high speed crashes, however, and abnormal TMJ motion during these types of collisions is unknown.)
The fact remains, however, that many whiplash patients experience TMJ pain. One group of doctors maintains that TMJ-and whiplash itself-are not real, physical conditions, but are social, or psychological, problems. In fact, "The belief that TMD is mainly a psychological affliction is so pervasive that a New England Journal of Medicine article recommended counseling as the main treatment for TMD."
A new area of research has grown in the last few years that suggests that TMJ pain after whiplash is indeed related to the whiplash injury, but that it is a myofascial problem related to the cervical injury, and not a direct lesion of the temporomandibular joint. The following description of the problem is from a current study on the issue:
"The functional interrelationship of the cervical spine and the jaw is not universally accepted, with some health professionals doubting any connection. However, physical therapists who treat musculoskeletal disorders, are familiar with the influence of dysfunction in a joint and surrounding muscles on adjacent joints (hip-knee, etc.). In the same manner, dysfunction of the cervical spine created by cervical hyperflexion-hyperextension (whiplash) can affect TMJ function."
"The TMJ, the occlusion, and the cervical spine are in close proximity and, from a functional point of view, are interrelated. Abnormal function or malposition of one of these parts can affect the function or positions of the others. For example, dentists usually adjust the patient's seated position before taking occlusional records, to prevent undesirable changes related to altered head positions. The cervical muscular reaction produced when the subject resists an applied lateral force to the mandible illustrates the close craniocervical functional relationship. In addition to affecting function, joints and muscles often refer symptoms to adjacent areas. Referred head and neck pain may be anatomically confusing, since referred pain does not travel down specific neural pathways, but is an error in cortical perception."
"Based on the head and neck functional interrelationship, whiplash injuries severe enough to cause cervical dysfunction may also affect, directly or indirectly, the TMJ and associated muscles, or may exaggerate existing TMJ dysfunction. Thus, a cervical dysfunction resulting from a motor vehicle accident (MVA) may cause and/or [exacerbate] TMD."
Based upon this premise that the TMJ and cervical spine are inextricably linked, the researchers set out to examine 300 patients who had a whiplash injury with subsequent TMJ pain. Each patient was given a thorough medical exam and history. Patients were excluded if they had a history of TMJ pain, if the accident resulted in direct jaw trauma, if the case was an Defense Medical Exam (DME), or if they were suspected to be malingering (i.e., exaggerated symptoms). The physical exam included a very thorough examination of the TMJ, including palpation of the muscles of the jaw and neck, and palpation of the cervical facet joints. The authors also palpated areas of the body unlikely to be related to TMJ pain; if the patients exhibited significant pain in those areas, the researchers concluded that the patients were exaggerating, and those records were excluded from the study.
The authors found the following:
Symptom Percent Jaw pain 96.7 Neck pain 87.0 Post traumatic headache 73.0 Jaw fatigue 65.0 Severe TMJ clicking 59.3 Episodic or complete locking 50.3 Low back pain 48.7 Orbital (eye) pain 42.7 Ear pain 37.0 Upper extremity symptoms 36.3 Anxiety or depression 34.7
- The researchers also found these abnormal findings:
Abnormal TMJ Findings Finding Percent Jaw Range of Motion Painful 53 Restricted 22 Hypermobile 15 Deviate 10 Muscle Tenderness Masseter Deep vertical fibers 83 Belly 16 Temporalis 15 Medial pterygoid 9 Trigger Points Masseter 51 Temporalis 15 TMJ tenderness Lateral 76 Posterior 33 TMJ disk derangements Clicking 47 Locking 23
Abnormal Cervical Findings Finding Percent Muscle Tenderness Trapezius 50 Suboccipital 41 Scalenes 41 Semispinalis capitis 37 Sternocleidomastoid 31 Posterior digastric 22 Paraspinal thoracic 16 Facet joint tenderness 71 Cervical range of motion Painful 65 Restricted 51
When putting all of this information together, the authors state that, "The most frequent components of the diagnosis of TMD were: myofascial trigger points, hyperactivity (spasms) of the jaw closing muscles, and TMJ synovitis."
The authors also address the issue of TMJ being primarily a psychological problem. "In the present study, we found obvious TMJ intra-articular disorders (significant clicking, locking, TMJ synovitis) in 258 patients (86%). This finding is difficult to ascribe to psychological or cultural factors. Of the 300 patients included in our study, 104 (34.7%) reported some anxiety or depression. We have noted these conditions in patients suffering from other painful disorders such as trigeminal neuralgia, and depression in migraine and tension-type headache is well known. However, this does not negate objective abnormal clinical signs-and treatment-for these disorders."
In conclusion, the anatomy of the neck/head complex, plus the evidence seen in this study showing widespread myofascial pain and tenderness lead the authors to the conclusion that the pain in the neck experienced by whiplash patients may very well be related to-or may even cause-TMJ pain and dysfunction. "Therefore, clinicians treating patients with whiplash injuries should examine both the cervical spine and the TMJ and its associated muscles. The authors recommend that the TMJ and surrounding structures be examined similarly to other synovial joints, with no preconceived notion that pathology after trauma is unlikely, psychological, or related to cultural influences."
"Regardless of the lack of knowledge on the incidence of TMD claimed to result from whiplash trauma, we believe that each case should be evaluated on its own merits by an experienced examiner. Clearly, some TMD cases similar to those examined in our study will be found to have resulted from the whiplash injury."
Friedman MH, Weisberg J. The craniocervical connection: a retrospective analysis of 300 whiplash patients with cervical and temporomandibular disorders. The Journal of Craniomandibular Practice 2000;18(3):163-167.
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