Handling TMJ (Temporo-Mandibular Joint) problems
Wow! My request for information about jaw problems in singers
clearly touched a nerve! Not literally.
We have a singer who has been diagnosed with TMJ, and I asked:
>(1) Has anyone seen something like this and seen it improve -- if
>so, what happened?, and (2) What sort of doctor deals with this sort
>of question -- physical therapist?
Our singer had also wondered if a volleyball injury had anything to do with it.
Here are the replies I got. I'm too swamped to annotate or organize
them, but I encourage anyone interested to read them all. There are
valuable differences of opinion, experience, perspective and
From Guy Durward :
>I have TMJ also and this has resulted in one side of my jaw being
>shaped differently from the other. It was not, however, a result of
>an injury....it resulted from grinding and clenching my teeth while
>I sleep. I suspect this may be the case with your girl also, as it
>can be a mark of tension and may also be genetic. (My mom, an opera
>singer, does this also.)
>The solution was to see an orthodontist, who made a night guard (in
>my case, a particular type called an Essex) for the lower and upper
>jaws. This has made a great deal of difference, in that it both
>prevents the grinding and breaks the habit. I would suggest that
>she get an orthodontic consultation. This can be fairly expensive,
>but is covered by some insurances and, in any case, is well worth
>it, because TMJ can cause all sorts of problems later on, including
>substantial dental repair which I have had to have.
From Carol Clary
>This condition is not uncommon. I see variations of TMJ very often in my
>college voice students and in my private studio. And, I am a TMJ survivor
>and finishing my doctorate in voice at the University of Southern California.
>I believe that there was an article in the NATS (National Association of
>Teachers of Singing) Journal in the last 3 years on this topic.
>Your singer should seek out a dentist whose specialty is in treating TMJ.
>Younger dentists in So. California routinely get this training so I am sure
>there must be someone in your area who has the extra knowledge. This dentist
>should give your student some exercises to stretch and release the muscles of
>jaw joints. Sometimes, bio feedback is necessary to change habitual
>offending bite or movement patterns. Often, a casting is made of the teeth,
>and the patient is fitted with a bite plate to wear at night. Additionally,
>planing (grinding off, uneven biting surfaces) to make a better bite pattern
>is usually done. Sometimes braces are necessary to move teeth into better
>alignment. In any case, this student should immediately stop chewing gum,
>ice and hard candy and take care of the problem. Untreated, TMJ causes
>headaches, deterioration of chewing surfaces, loss of high and low notes, not
>to mention a free functioning voice, clear articulation and resonating space.
> Vocal tone will usually be tight, limited and strident. And vocal progress
>will be very slow or actually worsen.
>Poor body balance (posture) with a forward neck and/or collapsed chest also
>aggravate the problem.
>Good luck with your student.
>Instructor at East Los Angeles Community College
>Formerly Adjunct Assistant Professor at California State University, Los
>Member of NATS
From Charles Rusizca
>Nina: I feel that the "three fingers" concept is really not an accurate
>bench-mark as to the space needed to sing properly. Some folks have large
>hands/fingers and cannot place three-fingers in their mouth. I strongly
>believe that if the jaw is unhinged--you can do this by placing your index
>fingers in front of the ear holes and dropping the jaw. You will feel your
>fingers go in behind the jaw joint/hinge. Thus, the jaw is unhinged. I
>have found much success with this technique. If the jaw is dropped too
>far, the back of the throat tends to close and thus, tension results.
>Only my thought. It might be worth experimentation.
From Frank Albinder
>Tell her not to open her mouth so wide! When I was in elementary school
>choir, we had the "three finger rule." It's ridiculous. Stick three
>fingers in your mouth and try and sing! It's painful, even if everything's
>normal. This reminds me of the guy who goes to the doctor and tells him
>that it hurts when he sticks his arm over his head. The doctor tells him
>not to stick his arm over his head.
>Of course, if she has TMJ, forcing the jaw open so wide to sing will
>exacerbate the problem. I say go with common sense and when it hurts, don't
From Peter Koster
>RECOMMENDATIONS FROM PRESCRIPTION FOR NUTRITIONAL HEALING BOOK - TMJ
>IS NOT THE
>ONLY DISORDER THAT CAUSES JOINT PAIN. ANOTHER POSSIBLE CAUSE IS RHEUMATOID
>ARTHRITIS. IF SYMPTOMS ARE MORE SEVERE IN THE MORNING AND TEND TO
>AS THE DAY GOES ON THEN R.A. COULD BE THE PROBLEM. IF TMJ IS CONFIRMED, 90
>PERCENT OF ALL CASES RESPOND TO SIMPLE INEXPENSIVE TREATMENT AND
>BE LAST RESORT SOLUTION. IF PERSON TENDS TO CLENCH AND GRIND TEETH
>THEN A SPECIAL
>BITE PLATE THAT IS WORN AT NIGHT MIGHT HELP. PHYSICAL THERAPY IS BECOMING THE
>MOST WIDELY RECOGNIZED VIABLE TREATMENT FOR TMJ. THIS MAY INVOLVE
>JAW AND TONGUE
>EXERCISES TO RETRAIN STRESSED MUSCLES, USE OF A TENS MACHINE, ULTRASOUND AND
>BIOFEEDBACK TREATMENT. 2,000 MG OF CALCIUM AND MAGNESIUM DAILY WITH VITAMIN
>B COMPLEX (100 MG) 3 TIMES DAILY. AVOID ALL SUGAR AND WHITE FLOUR PRODUCTS,
>ALL CAFFEINE ITEMS AND FAST FOOD AND JUNK FOOD. DO NOT CHEW GUM AND
>CHEWY FOODS SUCH AS RED MEAT AND BAGELS. EXPERIMENT WITH HOT AND COLD THERAPY
>WHICHEVER WORKS BEST. IF POSSIBLE SEEK HELP FROM PRACTIONERS WITH A
>DENTAL OR MEDICAL SCHOOL.
From Joellen Patterson
>Having worked for a physical therapist that worked with the TMJ
>problems, either a PT or even a massage therapist could help with
>the muscular problems related to it.
>I have had friends who are both teachers and singers who ended up
>with nodes on their vocal chords that had to go to speech therapists
>with specialties in working with singers. I think it might be worth
>a try to seek out such a specialist in your area and see if they
>have any ideas. Maybe positioning when she speaks and sings could be
>I bet a good oral surgeon, or perhaps better, a good orthopedist
>could help come up with a non-surgical treatment plan.
>I don't know if perhaps even a rheumatologist might be a good idea.....
From Gillian Brinston
>I too suffer from TMJ. I was diagnosed at the age of 12 and have been
>wearing a night splint for ten years. The splint is made out of a hard
>plastic and was constructed by an orthodontic surgeon. The Doctor gave me a
>series of exercises to do to relieve the muscle tension. When I was first
>diagnosed I could open my jaw to 22 millimeters measuring from the bottom of
>my top teeth to the top of my bottom. I now can open up 28-30mm depending
>if I have been wearing my splint all the time. The splint cost approx. $400
>Canadian and I had to replace it after six years. Some guidelines Megan can
>1. do not chew gum at all cost
>2. avoid hard candy and toffee
>3. make sure food is cooked to an easily chewable state
>4. Don't stop singing. By giving in we are not exercising our jaws, just
>letting them seize up.
>4. Try Ibuprofen for the pain verses acetaminophen or aspirin because it is
>an anti-inflammatory. If it gets worse a Doctor can prescribe Voltarine.
>TMJ is caused by clenching our teeth or grinding them when we sleep.
>Depending which way you grind will depend on which side of your jaw will be
>more affecting. It is probably safe to say the Megan did not injure her jaw
>playing volleyball, the ball very soft and your bones are fairly strong.
>The TMJ, I am sure, has come from years and years of grinding and clenching.
>I hope this helps. If you have any more question, please do not hesitate to
> We have a son that is, now, a opera singer - he suffered with TMJ
>(in high school) until he started wearing a guard at night. He felt
>so much better & could open his mouth much wider during the day,
>when he wore the brace that fit over his teeth at night.
>Also this jaw problem would show up big time when he was under a lot
>of stress. It's funny how things like that happen. Stress is an
>underlying cause of alot of ailments.
>I must tell you that most insurances do not cover TMJ. The
>insurance Co. thinks it's a dumping ground for jaw related things
>that are unexplainable.
>Good luck with this problem.
From Hakan Lindberg
>My name is Hakan, from sweden who joins the chorallist.
>I read your mail about the jaw problem on one of your singers.
>I also sing in a choir and I have found out that my jaw wants to
>move just a little to the side, also resulting in a small "klick",
>(just hearable in my head) , I asked a dentist and he told me it was
>beacuse of one of my wisdomtoth growing sideways in my upper jaw.
>I dont now if you can have any help out of my letter but i hope your
>choralsinger get better.
>Hope you understand my english.
From Sharyn Baker
>I have a similar problem with a hole in the disc in my jaw. I had dye
>injected into the joint to see all this. It probably arose because someone
>hit me in the jaw with a frying pan as a kid, and I too was hit by a
>softball on the jaw when I was older. I sang in the Occidental Glee Club and
>elsewhere and still sing.
>The condition also limits my ability to drop my jaw so far. But I believe
>that with good training and an understanding of the problem, that she can
>continue to sing and sing well. Sometimes people overly drop the jaw anyway.
>So some of the suggestions I have are that she learn to stifle her yawns a
>little, that she eats a little less food that is tough to chew and that she
>massage her jaw while practicing. I would also suggest ice alternated with
>heat for the jaw and perhaps even some sort of anti-inflammatory. Is she has
>a broken bone that needs to be fixed. But otherwise, I would caution her to
>get lots of opinions before she opts for any kind of surgery. Usually, these
>kinds of surgery then require that the teeth be realigned and all of a
>sudden, one is into thousands and thousands of dollars in bills and years of
>braces etc. In my situation, I decided I would live with the problem. Often,
>such surgeries are not successful and one is trading one kind of discomfort
>I hope this helps. If she can get two fingers in her mouth, that should
>still enable her to sing well.
From David Schildkret
>My daughter, who is now 11, was discovered to have what sounds
>marginally like a
>similar condition when she was about 8. In her case, the condiles
>of the lower
>jaw (the curved part of the bone at the top) did not develop properly. The
>result is that her jaw is slung back, giving her a tremendous overbite. She
>wears an orthodontic appliance at night to try to correct the
>problem; she will
>eventually need surgery (which is horrifying: it involves breaking the jaw).
>My suggestion is to get her to a good orthodontist. He or she may
>have more to
>suggest. Speech/voice therapists may have some experience as well. But I'd
>certainly start with an orthodontist. I'm surprised the dentist
>Best of luck to her. It was a real trauma for us when we learned of our
>daughter's difficulty (we thought we were going for braces, and this guy
>starts talking about degenerative diseases...thank goodness it has
>turned out NOT to be that!). The advice to stop singing when it hurts
>Here in Winston-Salem, there is a very fine otolaryngology team that
>specializes in the singing voice. I wonder if somewhere near you--like
>at University of Pennsylvania, or even in New York, there would be a
>person who specializes in singers' problems who might have some
>insight? Worth asking around.
From Judith Higbee
> I have had TMJ and when the dentist x-rayed he found that the painful
>side was flattened (no point however.) It is from wear and tear. A BIG
>factor is teeth-grinding at night. My dentist said that at first people
>deny it (as i did) but as then become more aware, they realize they are
>doing it. They may also wake up with headaches. After a round of
>prescription anti-inflammatories it improved and I also made a conscious
>effort to relax my jaw as I went to sleep. I haven't had a problem in over
>Once before when I had it, I was eating hurriedly and chomping on a hot dog
>rather vigorously (because of a tense conversation.) This and eating hard
>rolls also kicked it off.
>I don't think that surgery would be my first choice, either.
>Hope this helps.
From Tina Thielen-Gaffey
>I can give a little advice, as I have TMJ myself. I had huge issues
>with it as an undergrad and went through all of the pre-surgery
>things.....mouth splints, therapy, medication. However, my situation
>sounds a little like your sopranos......screwed up joint, not just a
>misalignment. Even though you say she was hit on the non troubled side,
>it could have knocked her out of alignment and that is the side that was
>affected. One of the first things they ask when you are having clicking
>and jaw issue is have you been in an accident or been hit in the face.
>I think there is much to be said for the fact that she was hit in the
>face, although I am no doctor! I ended up having "exploratory" surgery
>and they ended up putting in an artificial disc, as I didn't have one
>when they opened me up. They did surgery on the other side a few months
>I know the rule is avoid surgery as much as possible, but for me,
>surgery was a Godsend. I don't know how I could have functioned without
>it. I felt tremendously better, even as early as the recovery room. My
>face hurt, but my joints felt soooooooooooooooooooooooo much better, so
>I don't know that I would worry so much if surgery should happen. Of
>course, doctors know best. I did end up having a few more surgeries,
>mostly due to implant issues and bone splints, but I still feel a whole
>lot better. I have limited movement from side to side due to scar
>tissue, but I am able to open as wide as I need to function well as a
>singer. I do get headaches from it, but a good dose of Ibuprofen always
>does the trick. I have perscription doses in 800 mg and it always
>I hope this helps you understand a little better. I am happy to help in
From Brian Russell
>I, too, have suffered from TMJ and might have some
>In college, my jaw was locked (no more than one
>finger-wide opening) for about three months. All this
>was preceeded by years of popping and pain.
>Finally, I went to a specialist at Vanderbilty
>University Hospital (Nashville, TN) where I was to
>undergo surgery. My jaw bone, too, had been tapered
>just as you described about your student's. The
>surgery was to be as follows:
>The doctor was goin to make a vertical incision in my
>jawbone, then lower the upper portion of the bone,
>therby increasing the amount of space betweeen the
>"ball" and "socket." I was then going to have to have
>my mouth wired shut for six months.
>When he put me under for the procedure, he needed a
>few measurements of how far the opening was before and
>after. After he took the "before" measurement, he
>began applying pressure to see if he could force it
>open anymore. As he did, the cartilage between the
>ball and the socket, which was getting caught and
>making my jaw lock, ripped into three pieces! With
>the now smaller pieces, he was able to open my jaw
>back to its original size. He did not go ahead with
>the procedure but decided to see how it played out. I
>wake up every morning with my jaw locked, but it is
>easily unlocked. I enjoy a healthy career in singing
>and am pain free. The surgery was four years ago.
>Sorry for the long email, but I hope you can find some
>usefullness in here somewhere. Go to a specialist and
>ask about options - you might get lucky like me!
>Sorry for all the misspelled words and grammatical
>errors - I write this in haste, as such I end it also.
From Linda Tedford
>Last spring I was in rehearsal, opened my mouth a little too far and felt a
>def. crack in my right jaw. Over the summer it got worse, though I could
>Went to my dentist who diagnosed TMJ and made a device for me to wear almost
>constantly. It got much worse...I could not sing, had a hard time speaking
>to large groups..ie my choirs, and teaching voice lessons. It did improve
>immensely with my wearing the device, and over Christmas when I didn't do
>any rehearsals or lessons...had a month off...It feels a lot better, though
>still not back to normal. I have noticed that my jaw is "wierd...ie one
>side is higher than the other..whether that will resolve, I don't know.: do
>you want info from my dentist?
>It's very aggravating, frustrating, depressing.
From Brenda Kayne
>My niece has had TMJ for years and did recently have surgery. She is now in
>the mending process. She lives far from me and I was not aware that she was
>going to have the surgery - it seems so drastic. I think, however, that she
>is going to recuperate well IF and only if, she learns how not to carry
>tension in that part of the body. I truly believe that things like,
>massage, accupressure, yoga, and meditation - and a less stressful
>lifestyle - will help her. Even more important, (and if she were a singer
>I'd love to help her), is how she uses her breath and I mean every day
>breath. I think the phrase, "breathe into the area of pain" can be helpful
>to releasing that stiffness.
>It's amazing how badly singers can breathe - especially the dedicated ones
>who want to do well. I myself used to sing with a forward jaw in efforts to
>produce a good tone (there again, it was a matter of not relying upon the
>breath and lower support). I would get a very sore jaw.
>Another constant image that should be in the minds of someone with TMJ is
>that the jaw is a hinge - it falls back and does not just "opens wide". I
>think this is very important.
>In the case of your singer, it seems that if her jaw was hurt by injury,
>that she really should check out surgery or some kind of specific therapy to
>get back on track. This sounds like one for the specialists! I know that
>my niece will be having physical therapy soon. Don't know what she will be
>asked to do - but I'll be seeing her in February if you are interested in
>knowing about it.
>Brenda C. Kayne
From Emily McDuffee
>I am a music ed student/singer in college, and I have TMJ, but not
>too the point that your student does. My jaw clicks to its most
>open and then clicks back to close, so I cannot open it all the way
>while singing, and I have just learned to compensate - and that is
>why I tend to put too much control in my jaw. So, my dentist has
>fitted me for a splint that looks like a football mouthgard that I
>will wear to bed and it will hopefully remove some of the tension in
>my jaw and relieve that pressure. He also told me that orthodontics
>can help, but I already went through my three years of that in
>junior and senior high. So, have her ask her dentist about a night
>splint and maybe a retainer.
From Tim Hendrickson
>I don't know if I have an answer for you or not, but perhaps this
>information will help.
>My wife, who is also a singer - was diagnosed with TMJ a little over a year
>ago. She has almost the exact same problem - she used to be able to place
>three fingers in the space of her open mouth - and then it gradually became
>Singing has been extremely difficult for her. She has been to several
>different specialists and all but one said the same thing - surgery. A
>process in which they actually go in and break the jaw, re-set it, and then
>wire it shut. (Hence - realigning the jaw bones)
>Since this was not an option we were very enthused about, we sought the help
>of a different specialist. As it turns out, this new specialist offered a
>completely different approach - physical therapy!
>I scoffed at the idea at first - thinking that some type of oral surgery
>would ultimately be necessary. This doctor said the problem wasn't with the
>"jaw" but with my wife's spine. She began stretching my wife's back, arms,
>legs and had her sleeping with a special orthopedic pillow - ONLY on her
>BACK not on her SIDE. This method did in fact begin to correct her
>misaligned jaw bones - and her teeth began to meet properly.
>Within a month we noticed a marked improvement. The "click" that she would
>feel when opening her mouth wide to sing, or to eat was gone - and she has
>gained much of her unrestricted movement back.
>I don't know if this helps you or your student - but I strongly advise
>AGAINST any type of oral surgery if this physical therapy process will work
>in her case. I would seek the advice of a muscular/bone specialist BEFORE
>going to an oral surgeon.
>Hope this helps. I will be glad to give you the name of the physician my
>wife was seeing here in Michigan, if it will be of help.
From Michelle Feiszli
>Your e-mail was forwarded to me by Jim. Your question is an
>interesting one and I believe I can give you some information that may
>I am 30 years old and a singer. I have dealt with jaw problems most
>of my adult life. Originally it was thought that I just had a severe
>over-bite and an open-bite. (Open-bite is when the front incisors do
>not touch when biting into something, like a piece of lettuce.)
>While I was working for one of the top orthodontists in this country
>(Dr. James Evans, Rapid City, South Dakota), I had him look at my jaw
>for possible orthodontics to correct my bite. (side note: he treated
>me when I was a child and was interested in the fact that I had
>significant relapse - even with his excellent treatment.)
>After several series of x-rays, tomograms, and a visit to a
>maxillofacial surgeon, I was diagnosed with Idiopathic Condylar
>Resorption. It is a condition which causes TMJ-like symptoms (pain,
>clicking, & locking of the jaw joint) and affects women at precisely
>Megan's age, 18-24 years old.
>By definition, Idiopathic Condylar Resorption is "a progressive
>alteration of the condylar shape and decreased mass bilaterally, in
>temporomandibular joints that previously exhibited normal growth
>patterns with no identifiable precipitating event."
>The condyles of my temporomandibular joint are shaped like a spike and
>are nearly non-functional. I experience severe jaw pain and headaches
>which I've learned to control with medication and by wearing a
>jaw-splint called a "twin-block appliance" at night. It helps prevent
>clenching and grinding and works to move my jaw forward, relieving
>much of the pain. I've had quite a bit of success with this
>Having discovered that I am not a surgical candidate due to my age and
>the advancement of the condition, I have learned to "sing around" the
>problem. I have discovered internal resonance, the importance of
>relaxation of the vocal cords and jaw (I let my lower body do all the
>work!:)), tongue placement, and soft palate flexibility.
>You mentioned "three fingers vs. two" for space in the mouth. I have
>that to be a great source of jaw tension and creates a "swallowed"
>sound. I've tried thinking of "lifting the upper back molars" like
>there is something pushing up in the back, rather than opening the
>mouth more in the front. This may help Megan with some of the pain
>she is experiencing.
>I would recommend she continue to seek answers to her problem at this
>early age. You wrote:
> > I guess our questions are: (1) Has anyone seen something like this
> > and seen it improve -- if so, what happened?,
>The situation *can* improve depending on the form of therapy chosen.
>There are surgical solutions that may not be the "last resort", based
>on the latest research. There is also *management* of the symptoms -
>which is what I do.
> >and (2) What sort of
> > doctor deals with this sort of question -- physical therapist?
>I've not seen a physical therapist (not that I don't recommend it) but
>I would suggest she see an orthodontist and an oral surgeon to
>evaluate several things. 1) the current condition of her TMJ 2)a
>"base-line" set of x-rays etc. 2) is it progressing and how fast 3)
>treatment vs. management.
>Go to www.uic.edu and take a look at the information there. At their
>home page type 'Idiopathic Condylar Resorption' into the search
>engine. It will bring up a very thorough research article on the
>I hope this is helpful to you. I'd love to know what happens with
>Megan, as I am always looking for new ways to manage this problem!
From Joan Yakkey
>I had a Aunt with this problem and she had to wear a dental corrrection
>apparatus all night as she slept to reset the jaw and the teeth to coincide.
>Your student needs to take care of this urgently because it will lead to
>terrible headaches as time goes on.
From Wendy Catlin
>She might try a chiropractor(sp?) I had jaw problems after being hit on the
>one side-trouble started on the other, there is a muscle on the inside of
>the mouth in the back that she could learn to massage- and also try
>thinking of tension going to the other end of her body (like a big toe or
From Pat Lacey
> May I add a note from my dentist that was news to me (she gave me a
>printout on things to avoid, etc., but this was her personal addition to the
>traditional warnings). Students (and all of us) often sit with our hand
>under our jaw, sort of like Rodain's (sp?) "Thinker". My dentist pointed out
>how this puts great pressure on the jaw, so should be avoided. You may pass
>that hint along to those fighting this battle.
From Laura Ann Horwitz
>I recommend your student find a dentist who specializes in TMJ. What
>you describe are classic symptoms. I am a (professional) singer who
>has been treated for TMJ : treatment included being fitted for splints
>and eventually I wore braces (as a 35 year old!). It helped but never
>completed went away. (I did not have exactly the same symptoms you
>describe...but when I saw your subject 'jaw problems' I knew
>immediately it was a TMJ problem). Surgery was also a last resort
>option, which thankfully I never had to undergo.
>There is a TMJ clinic at UCLA~~ if you are unable to find a local
>specialist, maybe they can recommend someone in your area. Or check
>with local universities where there is a dental school.
From Stephanie Charbonneau
>I am both a singer and choir director - and I have TMJ. It is irritating,
>however my doctors/dentists have all said that I just need to deal with it.
>I take ibuprofen when it gets really irritated - but they are mostly
>right...you just stop singing or eating when it gets really bad. Eating
>anything crunchy just makes it worse - so avoid those sorts of foods if it's
>already feeling bad. Currently, my jaw pops EVERY time I open it
>widely...singing or not. Most of the time when I'm singing I do not open it
>all the way - thus avoiding the 'pop'! It all started when, at the age of
>four, I hit my jaw on a hard surface. Then at age 12, following toe surgery
>(when they had my mouth propped open for the breathing tube) it's started
>getting irritate again. It's been a problem ever since.
>Wish her good luck - and let me know if you find any solutions!
I hope others find these replies as informative as we do!
With many thanks,
| Nina Gilbert
| Director of Choral Activities, Lafayette College
| Easton, Pennsylvania 18042-1768
| phone 610-330-5677
| fax 610-330-5058