Thursday, September 29, 2011

TMJ syndrome, Behcet's disease and this dentist's point of view

TMD (Temporomandibular disorder, also commonly known as TMJ syndrome) problems can cause the following symptoms:

Ringing in the ears (Tinnitus)
Muscle tension in the head and neck
Interrupted sleep
Wear on the teeth
Popping in the joint
Pain in the teeth (cold sensitivity, pain to biting)
Loose teeth due to bone and periodontal involvement

I Behcet's you can have many of these things from other sources also, but many or all of these can potentially be helped with treatment for the TMJ problems.

The problems stem from the joint being pulled out of position by the teeth being in the wrong position. This can be treated by wearing a proper fitting hight guard (big emphasis on proper, the boil and bite kind will not help and can potentially make it worse). OR -- An equilibration which is a balancing of the teeth to position the condyle of the mandible in the right place. You will find dentists on both sides of the debate as to which is better. Simply put, they both work if done correctly. Neither work very well if not done correctly. So it is important to go to someone who has some experience with it and has had years of confirmed success.

Now the Behcet's part of it-------------- This is my theory/hypothesis. I have some practical, clinical experience with this, but I will be up front in saying that there is not any research yet to back this up.

The autoimmune part of Behcet's attacks the mucous membranes of the mouth and gut selectively more than anywhere else in the body. Thus the 100% of Behcet's sufferers that have apthous ulcers in their mouth at least some time during the course of their Behcet's if not constantly for decades. If you look at where tissues originate from, embryonically, there are various extensions from the mouth and gut that have the same origin and thus the same marker that the autoimmunity does the search and destroy on. One surface of the temperomandibular joint (TMJ) is lined with an epithelial layer. Embryonically, that epithelial layer is the same or very similar to the epithilium in the mouth. So my theory is that there is inflammation in the TMJ due to the autoimmune activity of Behcet's. The TMJ is unique in this way from any other joint in the body. So where the average person gets TMD because of the mal-position of the teeth and resultant muscle tension, someone with Behcet's has an added component.

You can get the teeth perfectly balanced and in the right position and then inflammation in the joint from a Behcet's flare can change that in a day. The problem is that if you re-balance the teeth to that position and the inflammation subsides, then all of a sudden the teeth are in the wrong place again and you have just undone the good that was done previously. So you adjust again and again if you don't recognized what is happening. With a night guard, you go though a cycle of it working and then not working, you get fed up and just stop using it all together because it is so frustrating.

My recommendation:

Do the equilibration (balancing of the teeth ) by someone with successful experience in doing that. Then know that that point is your solid, stable point and do no change it. When there is a flare and your bite changes due to swelling in the joint, you have a thin soft "night guard" that you wear will you sleep. It is essentially the same as a soft tray that is used for bleaching your teeth. It is there only to cushion you bite during the flare. It does not reposition your bite and it is not treatment. It will just minimize the damage done during the flare. But as the flare subsides, you will return to your home base of a solid stable position that will always be there. (At least usually). Without recognizing this issue, you become like a dog chasing it's tail. You will never find a stable place or a night guard that works long term because you will constantly be changing it.

My "Embryology Theory" in Behcet's (not an official term, just something to put a name to my thoughts about this concept) goes to other parts of the body too. The eustachian tube to the ear and part of the inner ear has that same epithelial lining in it, often causing hearing problems that come and go with flares. The thyroid is also an embyologic evagination from the gut. As is the anterior part of the pituitary. That is part of my theory/hypothesis of why there are so many endocrine problems associated with Behcet's.

Feed back would be appreciated of experiences regarding this. I think the more information that is passed back and forth the more we help each other.

David Petersen DDS


  1. Found your blog rather interesting. I haven't been fully diagnosed with Behcet's, but they have pretty much ruled every other disease out. But I too have had SEVERAL issues of mouth ulcers since May 2011, it is now Nov 2011, and I have not gone without a sore yet. I have also struggled with TMJ issues, and just recently thyroid issues (which I have never had before). Just thought I would let you know your theory/ hypothesis sounds so familiar to me. Makes me feel like I am not crazy for all the odd ironic symptoms I have from time to time. Thank you I enjoyed the read!

  2. Brandy,

    Thanks for the comment. Behcet's gives a myriad of symptoms that can be very confusing and frustrating. At the ABDA conference I saw many people that were comforted to find that their symptoms were not unique to just them. In my very small number of Behcet's patients in my practice, so far 100% of them have TMJ problems. Too small of a sample to make difinitive conclusions, but it does make me think and spur me on to research further.

  3. Hi David,
    I just saw this blog post -- add me to the BD patients with TMJ problems. I've always had clicking/popping in my jaw joints and some bad painful flares right at the joint, but things have gotten worse in the last year -- a couple of times when my teeth even stopped meeting on the right side while I was trying to chew something dense (I think it was steak). Now my "baseline" position is almost impossible to find. I need to find someone in the Boston area who can help me (preferably with a proper night guard as a first step). My own dentist offered to do it, but I don't trust he'd be able to do it correctly. Any recommendations? (I think you still have my email address) Thanks, David!

  4. David, I live in Australia, and after four years of docs trying to sort it out, just diagnosed with Behcets. Now with TMJ so bad it is hard to eat. Perfect logic in your theory, and I will be sharing your post with my dentist next week. I hope you keep publishing! And if seeking volunteers for research assistance, happy to help. Regards, James