The Jaw : Just When You Thought It Was Safe…

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mong singers’ acronymic medical problems, if TMJ is not first (GERD probably is), it is surely a close second. The initials stand for the temporo-mandibular joint, and refer to the contact point where the jaw hinges against the skull just in front of your ear. Unlike GERD, TMJ is not a disease (The proper term for a disorder is really TMD), it is a normal structure. Each of us has two, one on each side. (For those of you who collect “ too much information” there are animals that do not have a TMJ- they’re called lampreys, and completely lack a jaw).

The joint is a bit complex, and this complexity may contribute to the problems some experience. As you start to open your mouth, the joint acts like a ball-and-socket, with the ball-like head (condyle) of the jaw swiveling like a hinge. As the jaw continues to open, the condyle slides forward on a little cushion, until it is stopped by a small bony prominence (articular tubercle). You can feel the ball-like head of the jaw swiveling and sliding as you open and close your mouth by pressing your index fingers in front of the ear on each side. Better yet, put your index fingers, facing forward, into your ear canals, then open and close your mouth. If the jaw were to continue sliding forward over the bony bump, it would dislocate. Some people have dislocated their jaws, and experienced a great deal of pain, as well as the inability to close their mouth without medical help. (Again, there are animals that routinely and comfortably dislocate their jaws when eating, without pain or strain. They’re snakes, such as boas and anacondas, and their meal includes whole pigs.)

As you feel the head of your jaw rotating and sliding, it should be smooth, with no discomfort. If there is pain, or if you feel clicking or crunching as the joint moves, you have a problem that may need to be addressed.

TMJ problems can be acute or chronic, minor or major. The commonest cause of acute strain is excessive stretching of the joint, such as may occur during a prolonged session with the dentist. There is pain, spasm in the muscles of the jaw, and perhaps difficulty in fully opening the mouth. Some people can trigger TMJ discomfort by eating foods that require a lot of chewing, such as a steak, or even bagels. Chronic TMJ strain occurs when stressing activity becomes habitual. Chewing gum, especially bubble gum or “jaw breakers” (the name tells the story) should be limited or avoided. A dental filling left too high can throw off the bite and strain the two joint unequally. The most common problem in this category, however, is emotional clenching or nocturnal grinding of the teeth. Even if you sleep alone, you can tell if you grind: if you wake up with an earache, or sore jaws that don’t open easily, you may be a grinder. Wear patterns on the teeth also may point to grinding.

As stress to the joint becomes chronic, the joint itself may become damaged and arthritic. Naturally, it is best to address the problem as early as possible.

A relaxed jaw is especially important to singers. The muscles of the vocal apparatus are ultimately attached to the jaw (via the hyoid bone), and tension in the jaw is transmitted to neighboring muscles, negatively affecting the suppleness of the vocal apparatus. A tight jaw usually means a raised tongue, and a high larynx – all anathemas to good singing technique. It is in part for this reason that the first exercise in Singing 101 is to learn to relax the jaw, if necessary by initiating a yawn. If this is not mastered, tension in the muscles increases strain on the TMJ, pain develops, tension increases, and a vicious cycle begins.

So, all behavior that leads to jaw tension should be avoided. Chewing gum, clenching with emotion, any conscious behavior that causes pain (usually in, or just in front of the ears) must be addressed.

Nocturnal grinding is unconscious, and more insidious. Interestingly, allergies in the back of the throat can trigger this, and should be looked for. A bite guard, made by your dentist, can soften the “nightly grind”.

A new and promising treatment under investigation is the use of Botox to slightly weaken the muscles of chewing (don’t worry, they’re still plenty strong for eating, speaking and singing), and thus relieve the pressure on the TMJ.

There are, of course cases where surgery is necessary (and dramatically helpful) for severe temporo-mandibular joint disease. As always, if surgery is being considered, get a couple of other opinions.

But for most singers, the key is to be aware of both conscious and reflexive behavior which may be straining the jaw, and re-learn how to open and close in a relaxed and maximally effective way.

DISCLAIMER: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.

Anthony Jahn, M.D.

Anthony Jahn M.D. is an otolaryngologist with a subspecialty interest in ear diseases, disorders of hearing and balance, and disorders of the voice. He is a professor of clinical otolaryngology at Mount Sinai School of Medicine and is the noted author of Care of the Professional Voice. For more resources, go to his website www.earandvoicedoctor.com.