Dr Riyad AL-Habahbeh
Dental Department-Royal Medical Services-Jordan.
Dr Wajdi AL-Zioud BDS, JB (OMS)
Assistant Specialist-Oral and Maxillofacial Surgeon
Dental Department-Royal Medical Services-Jordan.
Dr Nemer AL-Khtoum MD, JB (ENT)
ENT Department- Royal Medical Services-Jordan.
Dr Riyad AL-Habahbeh
P.O.Box 732, Amman 11947, Jordan
Tel: 00962 777 919063
To investigate the prevalence of otalgia in patients
with temporomandibular disorders (TMD), and to
evaluate the response to conservative TMD treatment.
total of 125 patients with a diagnosis of some
form of TMD were clinically examined and interviewed
to disclose their TMD related complaints and to
reveal their pain scores, both at an initial visit
and after six months of conservative TMD treatment.
was a complaint in 46 patients (36.8%). Of the
125 patients, 86 (68.8%) were female. Following
the course of six-month conservative TMD treatment,
there was a significant decrease in overall pain
The prevalence of otalgia in patients with
TMD is high. In the majority of TMD cases, conservative
TMD treatment proved to be effective in controlling
TMD along with decreasing the pain scores including
Key Words: TMD (temporomandibular
disorder); otalgia;, pain.
(TMD) are defined as a collective term embracing a number
of clinical problems that involve the masticatory muscles,
the temporomandibular joint (TMJ) and associated structures,
or both" . They are considered to be a sub-classification
of musculoskeletal disorders, and typically run a recurrent
or chronic course, with a substantial fluctuation of
TMD signs and symptoms over time. Common signs and symptoms
of TMD are clicking or crepitation noises in the TMJ,
limited jaw opening capacity, deviations in the movement
patterns of the mandible, and masticatory muscle and/or
TMJ pain in the face [2,11].
Chronic pain in the
TMJ or the pain dysfunction syndrome is common affecting
15-20% of the population at some time in their life
Not only is the TMJ
the immediate anterior relation of external auditory
meatus, but also its capsule is supplied by an articular
branch of the auriculotemporal nerve that also supplies
cutaneous sensation to a large portion of the pinna
of the ear [4,10]. Not surprisingly, temporomandibular
disorders are frequently misinterpreted by the patient
Goodfriend (1933) ; an American dentist, is often
credited as the first to report a relation between otalgic
symptoms and the temporomandibular articulation.
Costen (1937) ,
described a syndrome consisted of a symptom complex
of loss of hearing, otalgia, tinnitus, dizziness, headache,
and burning sensation of the throat, tongue; originally
ascribed to over closure causing excessive backward
movement of the head of the condyle and pressure on
the auriculotemporal nerve. Currently, Costen's syndrome,
is recognized as not being well founded on anatomic
and physiologic principles. Moreover, Brookes, Maw and
Coleman (1980) , in a series of 45 patients with
TMD and aural symptoms were unable to find a direct
aetiological basis to link TMJ dysfunction and other
aural symptoms apart from otalgia.
Otalgia is a common aural symptom of functional disturbances
of the masticatory system; it is surprising that in
only less of 50% of the adult patients with otalgia,
it is possible to diagnose ear disease .
Few studies in the
literature focus on the occurrence, prevalence and treatment
of otalgia in TMD patients. The reported prevalence
of otologic complaints varies in the literature. However,
only few complaints are supported by audiometric documentation
. Most authors agree that the prevalence of otalgia
in TMD patients is in the range of 5-20% [12,13].
The aims of this study are to investigate
the prevalence of otalgia in a group of TMD patients
and to evaluate the response to conservative TMD treatment.
This prospective, clinical study was carried
out with TMD patients attending the dental department
at Prince Hashim Bin AL-Hussein Hospital of the Royal
Medical Services between February 2002 and January 2003.
A total of 125 patients diagnosed with
some form of TMD participated in this study; they were
divided into two groups:
Group 1 consisted of 79 patients (63.2%) with no ear
Group 2 consisted of 46 patients (36.8%)
who presented with otalgia along with TMD symptoms.
All patients in this second group were referred to an
ENT clinic and were examined by the otolaryngologist
before initiating TMD treatment to exclude organic ear
cause of otalgia.
The diagnosis of TMD was based on the
finding of at least two of the following features: limitation
of jaw opening, deviation of mandibular movement, joint
sounds (click or crepitation), pain on palpation of
the TMJ, and pain on palpation of associated muscles.
Because no apparent ear disorder was found,
no specific therapy for otalgia was initiated.
For both groups, a similar treatment protocol
was followed which consisted of TMD conservative treatment
policy: counseling, physiotherapy, occlusal splint therapy
and occasionally, non-steroidal anti-inflammatory drugs
(NSAIDs). In severe cases of acute osteoarthroses, intra-articular
steroid injections were carried out. In indicated cases,
some form of occlusal therapy (occlusal equilibration
or restorative treatment) was also performed, but only
after pain and most of the dysfunctional symptoms subsided.
Self-administered questionnaires regarding
the severity of pain were used to collect the data based
on a visual analogue scale. The patients were divided
into four groups according to severity of pain: no pain,
mild, moderate or severe pain.
The treatment outcome was evaluated by
improvement in the pain severity using the same visual
analogue scale questionnaires six months after first
examination and start of treatment.
Statistical analysis was performed with
the chi-square test. Significance levels of p< 0.05
Of the 125 patients, 86 (68.8%) were female
and 39 (31.2%) were male, they were aged 13-68 years
(mean 29.8 years).
Table 1 shows the age distribution of
79 patients (63.2%) had no ear complaint, while 46 patients
(36.8%) reported otalgia as a presenting symptom along
with TMD symptoms.
In the otalgia group, more women (67.4%)
than men (32.6%) had otalgia.
More patients in the otalgia group had
severe pain (19.6%) than patients without otalgia (13.9%);
however, this difference was not statistically significant.
In both groups, most patients complained
of moderate pain (75.2% of both groups). Figure 1 demonstrates
percentage distribution of patients at initial examination.
There was a statistically significant
decrease in overall pain experience in both groups six
months after initial examination and start of treatment.
Only 4.0% of the patients were found to
still suffering from severe pain as compared with 16.0%
of patients at initial examination.
23.2% of patients reported moderate pain,
while most of the patients (72.8%) ended with mild or
no pain; when compared with 8.8% of patients who had
reported mild or no pain at initial examination; in
both groups, this was statistically significant (p<0.05).
Figure 2 demonstrates percentage
distribution of patients six months
of initial examination and start of treatment.
There was no longer any significant difference
between the severity of pain experienced by both groups
six months after the first examination and the commencement
Figure 3 and Figure 4 demonstrate the
significant improvement in pain experience in group
1 (without otalgia) and in group 2 (with otalgia) respectively
following the six-month conservative treatment.
Finally, by the end of the six-month treatment
period, 54.3% of the otalgia-group patients no longer
had ear pain, and 30.4% experienced mild or occasional
This current study revealed a high prevalence
of otalgia in patients with TMD (36.8%). This was higher
than the frequency reported in most studies in the literature,
which ranges between 5% and 20% [12,13]. This difference
can probably be explained by differences in patient
material studied and in better estimation of prevalence
of otalgia in TMD patients that were carried out by
the dentist and the otolaryngologist in close cooperation.
Pain is one of the most disturbing of human experience,
and it must be remembered that individuals vary widely
in their appreciation of, and reaction to it, and the
same individual may react in different ways to a similar
pain at different times.
A higher pain level was found in TMD patients
with otalgia than in TMD patients without otalgia. Most
patients suffered from moderate pain.
Women had more incidence of otalgia
(67.4%) than men (32.6%). This warrants more investigation;
in their study of symptoms and signs of TMD, Kuttila
et al , concluded that women had more aural symptoms
than men. Literature review revealed that women report
symptoms of TMD at least twice more often than men,
also it has been stated that women are more likely to
have multiple TMD symptoms than men [11,20,24].
Six months after the first examination
and the start of conservative TMD treatment, the pain
score had decreased significantly in both groups. The
majority of patients (72.8%) ended with mild or no pain.
Earache disappeared completely in 54.3% of patients
initially presented with otalgia and TMD; otalgia was
mild or very occasional in frequency in 30.4% of patients.
In 15.3% of patients, no change in pain intensity or
pain frequency could be obtained.
Different theories have been proposed to explain the
occurrence of otalgia and other ear symptoms such as
stuffiness, tinnitus and hearing loss in association
with temporomandibular disorders.
Some investigators have hypothesized that Eustachian
tube dysfunction, masticatory muscle dysfunction, or
reflex sympathetic vasospasm of labyrinthine vessels
occurs secondary to abnormal stimulation of autonomic
nerves of the TMJ [7,19,20,22,23].
Some authors considered compression of
the external auditory meatus or of the auriculotemporal
nerve due to mandibular over-closure and posterior displacement
of the condyle a possible cause inducing the aural symptoms
in TMD [6,18], whereas others refuted this theory .
Moreover, reflex motion disturbances of
the tensor tympani and veli palatini muscles, as well
as the oto-mandibular tiny ligaments (diskomalleolar
and tympanomandibular ligaments); have been suggested
by some authors as being responsible for ear symptoms
, but other investigators could not confirm these
anatomic findings [16,17].
Other concepts that pertain to aural symptoms
of TMD have focused on the internal derangement of the
TMJ as a possible cause  and the direct mechanical
influence on nerve branches in the TMJ region [8,15].
Current explanation of otalgia occurrence
in patients with TMD stems from the complex innervations
of all parts of the ear and the phenomenon of referred
pain that probably can be explained by a central summation
mechanism in relation to gate theory .
Definitive conclusions on the direct aetiologic
mechanisms cannot be drawn from these studies because
the mechanism involved is not identical for all TMD
patients with otalgia. However, it should be always
remembered that pain is a warning and is always real
to the patient, and that if it is not possible to find
the cause of pain, this should be regarded as the physician's
responsibility rather than being the patient's fault.
- The prevalence of otalgia in TMD patients
- The conservative treatment is an effective
way for managing TMD patients, moreover, otalgia in
TMD patients did respond to the treatment protocol
instituted for all TMD patients.
- Close cooperation between the dentist
and the otolaryngologist is of paramount importance
in recognizing and diagnosing the TMD patients with
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