Clinical Relevance of Dental Parameters and Symptoms in Patients Suffering from TMD and Tinnitus and a Randomised Trial Measuring Symptom Relief after Using a Relaxation Device

Research Article

Austin J Dent. 2023; 10(1): 1174.

Clinical Relevance of Dental Parameters and Symptoms in Patients Suffering from TMD and Tinnitus and a Randomised Trial Measuring Symptom Relief after Using a Relaxation Device

Marie Tullberg, DDS¹*; Mattias Billing DDS, MSc¹; Göran Laurell MD, PhD²

1Specialist in Orofacial Pain and Function and Periodontology, Brahekliniken Stockholm, Sweden

2Professor at the Department of Surgical Sciences, Otorhinolaryngology and Head and Neck Surgery, Uppsala University, Sweden

*Corresponding author: Marie Tullberg, DDS Brahekliniken, Brahegatan 36, 114 37 Stockholm, Sweden. Email: marie.tullberg@brahekliniken.se

Received: June 02, 2023 Accepted: July 01, 2023 Published: July 08, 2023

Abstract

Aim: Tinnitus is a common symptom in dental patients presenting with Temporomandibular Disorders (TMD). In this study, 66 patients were examined and underlying variations in dental appearance, jaw position, jaw joint health, radiographic findings, and symptoms were recorded. The patients were randomly placed into either an intervention or a control group to assess the effectiveness of a relaxation device aiming to reduce tinnitus.

Method: 100 patients referred for TMD problems and suffering from tinnitus were asked to participate in the study. 66 patients completed two questionnaires before the first consultation with a specialist in orofacial pain and function and 46 of them completed the randomised trial.

Results: TMD patients most likely to be suffering from tinnitus had experienced stress, felt tension in the jaw or presented with neck problems. Clinical dental examinations revealed that these patients displayed a deep bite, had a click or scrape sound from their jaw joints and/or had parafunctional habits (grinding or clenching their teeth). Patients in the relaxation device group reported significant improvement at p<0.01 compared with control group after 4 months treatment.

Conclusion: This study presents general clinical signs and criteria that also non-dental medical professionals can use as a guide for referring tinnitus patients for specialist dental care. Patients under stress who are clenching or grinding their teeth, have missing teeth, midline shift and experience sounds from their jaw joints could benefit from examination by a dental specialist and the use of a relaxation device.

Keywords: Tinnitus; Temporomandibular joint; Risk factor; Symptoms; Treatment

Introduction

Previous dental studies have indicated that certain developmental positions of the upper and lower jaw and the teeth as well as dental and orthodontic therapeutic interventions can cause certain painful or uncomfortable symptoms in patients later in life. These are known as Temporomandibular Disorders (TMD) [1–3]. Other studies have reported that the pathological position of the jaws or disadvantageous of occlusal patterns do not because TMD, instead it is reported that the long-term effect of mastication and dysfunctional habits leading to stress that is a major source [4–6]. In this study we assess the subjective variations in the occlusion and bite in tinnitus patients presenting with TMD.

Reference

Dental (7), surgical (8) and orthodontic (9) textbooks teach us that the adult position and function of the upper and lower jaw depends on the skeletal development and on factors such as digit sucking habits, missing teeth (both aplasia and extractions), breathing challenges and trauma, previous dental or orthodontic intervention as well as parafunctional activity of the muscles and ligaments and the positioning of the condyle heads and discs in the temporomandibular joint. Many patients do not experience problems although they present with the most severe functional deviation and bite discrepancies. However, other patients with minor discrepancies can experience debilitating pain and symptoms possibly indicating that some interpersonal sensitivity to stress and pain influence on the patient’s experience [10,11]. Several studies demonstrate that tinnitus is more common among patients with TMD, which could be related to an increased muscular tonus caused by parafunction through teeth grinding and clenching of the jaws, particularly at night [12,13]. There are also suggested links between the presence of tinnitus in stressed patients with TMD [14].

Previous estimates suggest that approximately 10–20% of the European population suffer from tinnitus [15]. However, a study by Hasson et al. of approximately 9,756 individuals [16] found the prevalence of tinnitus in Sweden to be as high as 25%. Tinnitus is defined as an individual hearing a noise without external stimuli [14]. In most cases, tinnitus is reported by patients with sensorineural hearing loss such as presbycusis, acquired hearing loss after noise trauma, or use of ototoxic medications. The pathophysiology behind tinnitus is still unknown and there are reasons to believe that the site of pathophysiological mechanisms can vary and relate to lesions at different sites in the cochlea, central auditory pathways, or structures in auditory cortex [17–21]. Functional tests using SPECT and MR have also found that several locations in the CNS are involved in patients with chronic tinnitus [22,23].

Somatosensory tinnitus is when the tinnitus can be modulated by somatic stimulation or movement by for instance, the eyes or jaws. Somatic modulation has been reported to be observed in up to 83% of tinnitus patients, which could indicate that in some patients somatic or somatosensory tinnitus has its origin in disharmony and tension in the jaws and that this tension could be reversed by adjusting the lower jaw to a relaxed and comfortable position [24–27].

In this study, we first wanted to assess if there is an association between symptoms and certain dental parameters or jaw deviations in patients presenting with TMD and suffering from tinnitus. We also wanted to investigate the effectiveness of a jaw relaxation device in these TMD patients and see whether it could provide symptomatic tinnitus relief and could be investigated in future research and tinnitus referral frameworks or used as a comparison test in treatment outcomes.

Material and Methods

Patients with a combination of TMD and chronic tinnitus (chronic referring to duration of over 6 months) were examined by a dental specialist in orofacial pain and function in a specialist dental clinic in the centre of Stockholm, with the aim to investigate the association between TMD and tinnitus.

To participate in the study, the patients must have previously undergone a consultation with an ENT specialist or audiologist and been unable to receive tinnitus treatment from healthcare services.

Patients were excluded if they were undergoing any therapy that could affect the outcome of the present intervention, such as Cognitive Behavioural Therapy (CBT), dental treatment or soft tissue laser muscle treatment, or physiotherapy. Patients received two questionnaires via post before attending the clinic – a HADS questionnaire [28] and a non-validated study-specific tinnitus questionnaire. They also received written information about the study.

The HADS scale was used to determine whether the patients were affected by anxiety and/or depression. In contrast, the study-specific tinnitus questionnaire asked patients to specify the variety of symptoms they had, their onset, and complaints. There were also questions covering previous dental history and history of specialist dental treatments.

Patients participating in the randomised study of the relaxation device were asked to complete a follow-up questionnaire both at the start and upon completion of the study. This questionnaire asked about the symptoms of the tinnitus sounds they heard in terms of pitch, modulation, and impact.

100 patients were offered appointments to participate in the study, and 98 agreed. 32 patients did not fill in the forms correctly, failed to show up for a clinical examination or declined treatment. We were then left with 66 patients suitable for assessment, all having consented to the study. These patients underwent a clinical evaluation of their teeth, bite, and jaw relationship. Clinical photographs of the patient’s teeth and face were taken during this examination, and measurements relating to a deviation from a neutral Class I bite were recorded. An OPG radiograph was also taken to exclude any underlying dental pathology that could interfere with the study or needed immediate treatment.

The patients were randomly assigned to an intervention group and a control group by terms of lottery before they came to see the specialist for the assessment. Patients in the intervention group received a bag of 5 relaxation pegs (Gapnap®, Sweden), to use to relieve the muscular tension in the jaws, head, and neck region. These patients received written instructions on how to use the device but received no verbal information to keep the study as non-biased as possible and patients were asked to fill in a diary to measure compliance. They were also advised to use the peg several hours per day, especially when reading, driving, working on the computer or online, watching television and even playing golf. The control group received no treatment. Figure 1 shows the placement of the relaxation device between the lips as per initial instructions.