This clinical research was done on patients who were referred to the clinic by ENT specialists, for the treatment of temporomandibular joint disorders. Total of 8 patients who had complaints of bruxism & tinnitus were taken into account for this clinical research. Tinnitus was resolved using mouthguard and medication, both within the scope of dental surgeons. Thus, this article provides a new understanding that tinnitus due to temporomandibular joint disorders can be treated by dental surgeons.
Tinnitus, or ringing in the ears, is the sensation of hearing ringing, buzzing, hissing, chirping, whistling, or other sounds. The noise can be intermittent or continuous, and can vary in loudness. It is often worse when background noise is low, so the patient may be most aware of it at night when they’re trying to fall asleep in a quiet room. It maybe associated with hearing loss, although it does not cause it.
Prolonged exposure to loud sounds is the most common cause of tinnitus. It causes permanent damage to the sound-sensitive cells of the cochlea of the inner ear. A variety of other conditions and illnesses can lead to tinnitus, including:
- Natural aging process
- Blockages of the ear due to a buildup of wax, an ear infection, or rarely, a benign tumor of the auditory nerve.
- Certain drugs like aspirin, several types of antibiotics, anti-inflammatories, loop diuretics, and antidepressants, as well as quinine medications.
- Meniere's disease
- Other medical conditions such as high blood pressure, cardiovascular disease, circulatory problems, anemia, allergies, hypothyroidism, autoimmune disease, and diabetes
- Head and neck injuries and
- Temporomandibular joint (TMJ) disorders.
The treatment of tinnitus due to TMJ Disorders involves mouthgaurds and certain drugs such as paroxetine. Both these treatment modalities are within the scope of dental surgeons. Thus, this article provides a new understanding that tinnitus due to temporomandibular joint disorders can be treated by dental surgeons.
This clinical research was done on patients who were referred to the clinic by ENT specialists, for the treatment of TMJ disorders. Total of 8 patients who had complaints of bruxism & tinnitus, were taken into account for this clinical research. An X ray of TMJ (both opening & closed) was advised. X-ray reports confirmed that the patients were suffering from different types of TMJ disorders.
The treatment prescribed was use of bite & boil mouth protector mouthguards at night for 6 weeks. Mouthguards prevent bruxism which causes muscle pain and tension, and help to stabilise the TMJ. Out of 8 patients, 4 patients said that by the end of 3rd week, the problem of bruxism & tinnitus started to cease but the patients did feel some sort of pain. To get rid of this, the patients were prescribed Etrocoxib MR(muscle relaxants). They were relieved of pain.
The other 4 patients said that the problem of tinnitus was still there even after using mouthgaurds for 3 weeks with no relief. For these patients, a drug called Paroxetine 20 mg was prescribed to be taken at bed time (after dinner in OD dose) for 3 weeks. Although this drug is primarily an anti-depressant, it increases the activity of tongue muscle genioglossus, which is important for the tongue’s stable positioning. The affected patients were asked to continue using mouthguards for 3 more weeks. At the end of 6th week, these 4 patients too got relief from tinnitus due to TMJ disorders.
It must be mentioned that though all the patients got relieved from tinnitus due to TMJ disorders, they did show other signs & symptoms of TMJ disorders for which they were recommended physiotherapy.
A total of 8 patients were taken into account for this clinical research, who had complaints of bruxism & tinnitus. Tinnitus was resolved using mouthguard and medication, both within the scope of dental surgeons.
The X-ray view advised for TMJ was axiolateral view. The details of the radiographic view were as follows:
- Central ray 25-30 degree caudad, centred 5 cm superior & 1 cm anterior to the external auditory meatus.
- Collimation: No more than 10 x 10 cm with TMJ & area of external auditory meatus of interest.
- Orientation: Portrait
- Detector Size: 18 cm x 24 cm
- Exposure: 70-75 kVp; 16-25 mAs
- SID: 100 cm
- Grid: Yes
Mouthguards prevent bruxism which causes muscle pain and tension, and help to stabilise the TMJ. This inturn, may stabilize a misaligned eardrum too and reduce ear symptoms (tinnitus) caused by TMJ disorders. The mouthguards prescribed were bite & boil mouth protector mouthguards as these are easily available in the market. The usual custom fitted mouthguards which are made in dental labs were not advised, as the fabrication of these type of mouthguards take time and the patients were all urgent referrals from ENT surgeons. Bite & boil mouth protector mouthgaurds are made of thermoplastic material and are placed in hot water to soften, then placed in mouth & shaped around the teeth using finger & tongue pressure.
The drugs prescribed were:
1. Etoricoxib MR. Etoricoxib is a selective COX-2 inhibitor used to relieve moderate post-surgical dental pain as a short-term treatment and inflammatory and painful symptoms of various forms of arthritis. It’s muscle relaxant effect took care of pain due to any acute muscle tension or minor gingival injuries caused by the mouthguard.
2. Paroxetine 20 mg. Paroxetine is primarily an anti depressant. It increases the activity of genioglossus muscle. Genioglossus is considered as the safety muscle of tongue. Stable positioning of tongue is very necessary to control bruxism & it is the genioglossus muscle which maintains the stable position of tongue and advances the tongue. Paroxetine prevents the tongue to collapse posteriorly overtime as genioglossus weakens with age.
Pain reducing ear drops are generally prescribed for tinnitus but should be avoided as first line of treatment for tinnitus due to TMJ as it makes the treatment more confusing without giving any good prognosis in the end.They may cause allergic reactions in the ear which can complicate the prognosis of the temporomandibular joint disorder treatment and hence must be avoided. In addition, it has been found that some pain reducing ear drop may cause a blood disorder named methemoglobinemia in rare cases.
From the above clinical research, it can be concluded that to relieve patients from tinnitus due to TMJ, use of mouthguards for 6 weeks along with a muscle relaxant is an appropriate treatment approach. After 3rd week, if patient is not relieved from tinnitus, then the drug Paroxetine can be given along with the use of mouthguards at night. Thus, the new understanding is that for tinnitus due to TMJ, mouthguards can be considered as the first line of treatment and drug paroxetine along with mouthguards as the second line of treatment (within the limitations of a small sample size). Use of mouthgaurds is the best non surgical option for treating tinnitus due to TMJ Disorders, as mouthgaurds helps to stabilize the TMJ and probably a misaligned eardrum too.
Dr Mriganka Sekhar Ghose;BDS(Gwl) ;Paed Dent Spclty Prog(Royal College Of Surgeons Ireland), Cert in Evidence Based Medicine(PGI Chandigarh).
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