Domestic Violence Increases Risk of TMD

Domestic Violence Increases Risk of TMD. How Intimate partner violence may cause painful temporomandibular joint disorders.

Domestic Violence Increases Risk of TMD

By Julia Worrall RN, CCRN, SANE | Reviewed by Ann McCullouch

Are you aware of the link between domestic violence, intimate partner violence (IPV), and painful temporomandibular joint disorders (TMJ)?

The World Health Organization’s Violence against Women Fact Sheet notes that “While much of the focus on brain injury has centered on athletes and military veterans, victims of domestic violence (DV) comprise an under-represented cohort.” It goes on to relate that the “majority of domestic violence cases have a history of trauma to the head or neck resulting in both TBI and oral maxillofacial damage.” [1]

This statement should prompt more clinicians to ask questions that may surface the cause that triggers a patient’s TMJ symptoms. Patient safety is a priority for all healthcare practitioners. First, let’s define a few key terms that will help our conversation here.

Table of Contents

What is Intimate Partner Violence?

Intimate Partner Violence (IPV) is a serious public health issue that can have far-reaching implications.

It commonly manifests as physical and/or psychological/emotional aggression within a relationship. It is more commonly known as “domestic abuse”, “spousal abuse”, an “unhealthy relationship”, or an “abusive relationship”. Importantly, this can be present in any type of domestic partnership setting, not just romantic ones. Regardless of the nature of the relationship, IPV involves patterns of controlling behaviors that cause physical, emotional, and/or psychological harm to those involved.

Some common types of IPV include verbal assault or coercion, economic or financial control over another person, stalking or harassment, and even sexual coercion. In all cases, IPV severely impairs an individual’s sense of personal autonomy and can have serious long-term effects on physical and psychological well-being.

Have you ever stopped to think about the connection between Intimate Partner Violence (IPV) and temporomandibular joint disorders (TMD)? On the surface when we think of IPV, injuries that can be seen on the outside usually come to mind. But research has found surprising links between TMD – a type of chronic pain disorder caused by problems with movement in the jaw – and intimate partner violence. This means even if physical domestic abuse is not visible externally, there could still be hidden effects on one’s health occurring internally.

“The etiology of TMD is multifactorial and includes biologic, environmental, social, emotional, and cognitive triggers. Diagnosis is most often based on history and physical examination.” From the article Diagnosis and treatment of temporomandibular disorders (American Family Physician Journal March 15, 2015) [2]

Studies show a strong correlation between symptoms of the temporomandibular joint disorder (TMD) and physical, emotional, and psychological abuse from an intimate partner or family member. This knowledge gives us insight into how interrelated mental health and physical health are – even when it comes to conditions like TMD which, at first glance, appears to only affect a single area of our body. In this article, we will explore the connection between TMJ pain and Intimate Partner Violence (IPV) further, discussing potential causes and how these issues can be addressed in order to achieve long-term wellness.

What Impact Does Domestic Abuse have on Mental Health?

Psychological stress is a significant factor in domestic violence situations, which can exacerbate the perception of pain through the central sensitization of the nervous system. This heightened pain sensitivity may further implicate neuropeptides like calcitonin gene-related peptide (CGRP) and substance P (SP), which are known for their involvement in pain transmission and inflammatory processes. [3]

How might domestic abuse lead to TMJ?

The relationships of collagen and elastic fiber groups within the TMJ disc are complex. A blow to the head may damage them. The articular disc is a fibrous extension of the capsule that runs between the two articular surfaces of the temporomandibular joint. These connections are important to the behavior of the articular disc in the normal joint and influence proper jaw functions.

“Domestic violence continues to be a global public health issue, and facial injuries in these cases are common with a reported incidence of up to 94%”, according to Holly Boyes in the Maxillofacial injuries associated with domestic violence: experience at a major trauma centre NIH article.

Published 1 February 2020, the study aimed to identify patients with facial injuries caused by domestic violence. It also reports that “punching was the most common mechanism” of domestic assault.

Victims of IPV may experience significant psychological disturbances. These disturbances don’t just manifest in the short term—they may last long after the abuse has stopped. A person’s psychological stress state when facing anxiety and depression can trigger clenching and grinding of the teeth. “Besides, psychological stress can cause spasms and disharmony in the chewing muscle groups,” according to the National Institute of Health. [4]

Some mental health problems associated with IPV include:

  • Depression
  • Anxiety disorders
  • Post-traumatic stress disorder
  • Substance abuse

Persistent stress and trauma from domestic violence can also lead to maladaptive coping strategies such as clenching or grinding of the teeth, which puts excessive strain on the TMJ and surrounding musculature. This additional stress on the joint may contribute to dysfunction or inflammation, increasing the likelihood of developing TMD, headaches, and other pain syndromes. It’s important for mental healthcare professionals to be cognizant of this connection, as timely diagnostic intervention and treatment can help victims regain their quality of life. [5]

What Symptoms Domestic Abuse Victims may have that Signal TMJ?

The physical manifestations of IPV can extend beyond the expected trauma of bruises and broken bones, as with TMDs. Nerve and joint damage can occur when a person is forced to clench their jaw or suffer a direct blow repeatedly. Prevalent forms of domestic abuse include being struck on the face or head. [6] Too often, jaw injuries are the results.

Common TMD symptoms that a domestic abuse victim may experience:

  • Facial pain.
  • Jaw tenderness.
  • Difficulty chewing.
  • Limitations in opening the mouth wide.
  • Ringing in the ears.
  • Headache.
  • Earache.
  • Sensitivity/tenderness on the sides of the face.

It’s important to recognize that Physical Symptoms of TMJ disorders related to IPV can become quite serious if untreated. Early intervention is critical to avoid these painful complications from developing.

Traumatic experiences, particularly those that involve physical or sexual assault, can result in enduring psychological and physical consequences for the victim. Post-traumatic stress disorder (PTSD) and TMD are two conditions commonly correlated with domestic violence and other forms of trauma.

Additional Factors Contributing to TMD

Here are some additional factors that can contribute to TMD development:

Female Gender: The female gender seems to be a strong predictor of TMD pain and TMJ sounds. This may be because women generally have a higher prevalence of physical and sexual abuse and face unique hormonal factors that could contribute to an increased risk of TMD. Gender-based violence has become a nationally recognized issue of concern. Additionally, social and cultural expectations may create added stressors for women, leading to increased TMD symptoms.

Age: Increasing age is another powerful predictor of TMD pain and TMJ sounds. As individuals age, the chances of experiencing various forms of trauma, stress, or assault may increase, leading to a greater risk of developing TMD. Moreover, age-related changes in the structure and function of the temporomandibular joint and surrounding muscles could contribute to an increased vulnerability to developing TMD symptoms.

Bruxism: Sleep bruxism, or the unconscious grinding and clenching of teeth during sleep, has been identified as a leading predictor of TMD pain. This nocturnal habit exerts excessive pressure on the temporomandibular joint and the surrounding muscular structures, causing inflammation, pain, and damage over time. Sleep bruxism may be prompted by various factors, such as stress, anxiety, and sleep disorders, which are common consequences of traumatic experiences.

Lip biting: Biting on lips and/or cheeks was found to be a significant predictor of both TMD pain and TMJ sounds. This oral parafunctional habit increases strain on the temporomandibular joint, irritates the surrounding muscles, and could potentially damage the joint, resulting in increased TMD pain and TMJ sounds. Similar to bruxism, biting on lips and cheeks may be a stress-related behavior triggered by traumatic experiences.

Stress: Stress has been recognized as a crucial factor in predicting TMD pain. It is essential to consider the relationship between stress and traumatic experiences, as individuals who A experienced trauma may exhibit amplified stress responses. Heightened stress levels can induce muscle tension, especially in the jaw and face. This may lead to habitual teeth clenching or grinding, which contributes to the development and perpetuation of TMD pain.

Depression: Feeling sad was identified as a strong predictor of TMD pain. Feelings of sadness and depression often accompany traumatic experiences and can exacerbate pre-existing TMD symptoms or contribute to the development of new ones. These negative emotions may manifest in various physical symptoms, including increased muscle tension and pain, further exacerbating TMD pain.

Intimate partner violence can contribute to TMDs, headaches, and various pain syndromes through numerous mechanisms. One of these mechanisms involves the impact of physical trauma on the distribution and function of neuropeptides in the articular disc of the TMJ.

The articular disc facilitates smooth TMJ movement. It contains various nerve fibers that express neuropeptides like CGRP, SP, vasoactive intestinal polypeptide (VIP), and neuropeptide Y (NPY). All of these have roles to play in modulating jaw joint pain and blood flow. Most of these nerve fibers are concentrated in the posterior attachment and anterolateral loose fibrous tissue regions of the TMJ articular disk.

In cases of domestic violence, victims often suffer from direct physical injuries, including facial or jaw trauma, which could potentially impact the TMJ and surrounding structures. This trauma may lead to inflammation or damage to the nerve fibers within the TMJ articular disc that express neuropeptides, resulting in the dysregulation of their functions in pain sensation and blood flow regulation. Consequently, this can contribute to the development of TMD, headaches, and other pain syndromes.

How does Centralized Pain Cause Chronic Pain?

Chronic pain is a persistent and long-lasting discomfort that can affect various parts of the body. One of the reasons behind chronic pain is a process called central sensitization, which is a heightened sensitivity of our nervous system to pain due to specific changes in the brain and spinal cord. Neuroinflammation, or inflammation of the nerves, contributes to this process and can lead to chronic widespread pain.

Intimate partner violence, typically involving physical, emotional, or psychological harm, can contribute to chronic pain through various mechanisms. When a person experiences IPV, they may suffer from painful physical injuries. These injuries can then prompt a response in their nervous system, leading to neuroinflammation and the activation of glial cells (support cells) in the brain and spinal cord.

How glial cells drive pain signaling:

When glial cells are activated, they produce substances called cytokines and chemokines. These molecules are known to regulate inflammation and immunity, but they can also act as neuromodulators – substances that change the function of nerve cells. If cytokines and chemokines are continuously produced in the central nervous system due to ongoing IPV, they can increase sensitivity to pain, eventually leading to chronic pain. [7]

It is important to note that the impact of IPV on chronic pain may vary between the sexes. Research shows that there are differences in the way males and females experience pain, including how glial cells and immune signaling contribute to the development of chronic pain. Therefore, the relationship between IPV and TMD might be influenced by the victim’s gender as well.

Given the role of neuroinflammation in chronic pain, new therapeutic approaches are being developed to target and control neuroinflammation. By addressing the root cause of chronic pain, these treatments may provide an effective way to alleviate pain and improve the overall quality of life for those who have experienced IPV and suffer from chronic pain. Understanding the connection between IPV and TMD, as well as the factors that can influence this relationship, has helped researchers and clinicians to develop a better approach for individuals affected by both conditions.

From a TMD practitioner’s point of view, domestic assault research provides important signals to look for when treating patients.

Intimate Partner Violence and Temporomandibular Joint Disorder Study

A March 2019 Intimate partner violence and temporomandibular joint disorder report revealed a moderate association between Intimate partner violence exposure and subsequent development of TMD. The clinical significance of the study’s discovery is that individuals presenting with TMD should be screened for IPV. Joht Singh Chandan from the University of Birmingham highlights how this could help detect cases of domestic abuse and provide support for those in need.

Domestic violence screening can be difficult, so it is important to know which questions to ask. The HITS is a four-question, self-reported or staff-administered screening tool that assesses the frequency of certain components of IPV. It uses a five-point Likert scale from 1=Never to 5=Frequently:

  1. Do you feel controlled or isolated by your partner?
  2. Does your partner ever try to control you by threatening to hurt you or your family?
  3. Has anyone close to you ever threatened or hurt you?
  4. Does your partner ever hit, kick, hurt, or threaten you?

These questions can help to identify domestic violence. It is also beneficial to provide resources such as information on domestic violence awareness and hotlines should an individual need assistance.

For anyone suffering from domestic abuse that is reading this article, we want to provide some immediate guidance.

Helping a domestic abuse victim stop stress-induced jaw clenching

Survivors of IPV with TMD symptoms should learn to practice self-care to manage their condition. Early intervention is the key to the successful treatment of TMDs. [8]

Here are some self-care measures to lower the risks of developing TMJ:

  1. Jaw Rest: It’s important to rest the jaw as much as possible, take ice and heat on the sore areas, and stay away from hard foods. Diet modifications may also help reduce the intensity of pain felt in the jaw muscles or joints due to the nerve endings spasming.
  2. Physical Therapy: It may also be helpful to do stretching and relaxation exercises to loosen any constricted muscles. Chiropractic adjustments and or massage therapy are also excellent resources used by successful TMD sufferers to help with physical therapy.
  3. Specialized Care: Find a knowledgeable specialist who works with domestic violence survivors and can help understand how emotional factors such as stress, fear, depression, and anxiety can affect TMJ pain. As with any chronic condition, communication and support play a vital role in achieving positive outcomes; discussing symptoms and obtaining emotional support will benefit those suffering from TMD greatly throughout their treatment journey. An orofacial pain specialist is a trained professional who can best assess TMD symptoms.
  4. Mental Health Exercises: Set aside daily time for calming activities like reading or listening to music that can reduce tension in the jaw muscles. Exercise and relaxation techniques have been found to be effective treatments for managing symptoms. Distractions activities like reading a book can often be helpful when trying to cope with primary symptoms such as constant headaches, ringing in the ears, and tenderness around the jaw area.
  5. Personal Safety for Overall Health: Ensure you take all the necessary precautions to stay safe if you are still in an abusive relationship.

These tips should help lessen symptoms of TMJ due to IPV and restore your required quality of life.

An anterior bite plane splint helps avoid the posterior teeth from contacting each other. Preventing the back teeth (molars) from touching each other helps to disrupt the abnormal muscle activity (known as pathological muscle firing) that occurs when a person grinds, gnashes, or clenches their teeth unconsciously.

Molars have a key role in this condition due to their role as the primary force transmission area for clenching. This means that the molars are responsible for transferring and distributing the forces generated by jaw muscles when we bite, especially during clenching tasks. [9]

The stiffness of the bite substance – the material used in the anterior bite plane device – is an important factor in this process. Although it doesn’t change the force transmission patterns, it can impact the maximum contact stress levels on the discs, which cushion the jaw joints (TMJ), and the occlusal surfaces, which are the biting surfaces of our teeth.

When a person clenches their teeth on one side during sleep bruxism, the high-stress region on the discal surfaces (the areas of the TMJ discs that come into contact with the bite substance) shifts towards that side. This shift can result in increased pressure on the TMJ, leading to temporomandibular disorders, pain, and discomfort associated with sleep bruxism.

By wearing an anterior bite plane device or a prefabricated splint during sleep, it is possible to prevent the molars from touching each other, which can help interrupt the abnormal muscle activity associated with clenching. These devices essentially act as a cushion between the molars, effectively redistributing the forces and significantly affecting the biomechanical response of the entire masticatory system (i.e., teeth, muscles, and jaw joints). This change in force distribution thus contributes to the reduction of jaw muscle activity during sleep and alleviates the symptoms of temporomandibular disorders. [10]

Table – Statistics Showing the Persons Most Often Impacted by IPV

Domestic Violence affects individuals in every community.

People of all types have become domestic abuse victims; regardless of age, economic status, sexual orientation, gender, race, religion or nationality. If you are a victim, you are not alone!

Demographic characteristics of intimate partner violence advocates (total n = 53) who participated in interviews

Race/Ethnicity Participants (n/%)
Asian 5 (6%)
Black/African American 6 (11%)
Latinx 7 (13%)
American Indian/Alaska Native 4 (8%)
White 30 (57%)
Other 3 (6%)
Gender Participants (n/%)
Female 49 (92%)
Male 1 (2%)
Transgender, Gender queer, Non-binary 3 (6%)
Years as an advocate
Minimum 5 months
Maximum 46 years
Average (years) 10 years
Region Participants (n/%)
Midwest 12 (22%)
Northeast 13 (25%)
South 10 (19%)
West 18 (34%)
Culturally-specific Participants (n/%)
Agency 11 (21%)
Program 3 (6%)
Populations Served (Majority)a Participants (n/%)
Black 11 (21%)
Disabled 2 (4%)
Immigrant 15 (28%)
LGBTQIA+ 8 (15%)
Limited English Proficiency 11 (21%)
Indigenous 8 (15%)

Based on United States IPV advocates’ experiences working with survivors, Published Oct 26, 2021 [11]

Intimate partner violence (IPV), defined by the US Centers for Disease Control and Prevention as ‘physical violence, sexual violence, stalking, or psychological aggression by a current or former partner or spouse,’ is a pervasive public health problem. One in four women in the United States have experienced physical violence, sexual violence, and/or stalking with IPV related impact; 1 in 3 have experienced psychological abuse.” – The Journal of Family Violence (JOFV) in partnership with the National Institute of Health (NIH)

SUMMARY: Proactive Care for Domestic Abuse Survivors

In conclusion, IPV can deleteriously affect the temporomandibular joint through various pathways, including direct physical trauma, psychological stress, and maladaptive behaviors. These intertwined factors may contribute to the development of TMD, headaches, and other pain syndromes, further emphasizing the importance of addressing the associated sequelae and preventing domestic violence in our society.

Proactive care as described here is possible with the Speed2Treat Kit for Head, Neck, & Jaw Injury, which offers easy, at-home treatments tackling all parts of IPV-related TMD, including neck pain reduction strategies, swelling reduction strategies, neuromuscular signal interruption, and more. By acting early and using products like this one, you can help reduce the burden of IPV-related TMD and regain quality of life faster.

Learn of Helpful Products for Treating TMJ

Author bio

Author Julia Worrall RN, CCRN, SANEJulia Worrall RN, CCRN, SANE, Editor-in-Chief at The Sleep RN, has extensive experience in the field of domestic abuse. She has been a Domestic Violence/Sexual Assault Nurse Examiner (SANE) since 2001 and the Program Lead for the Domestic Violence and Sexual Assault Program at Headwaters Health Care Centre.

Reviewer bio

Author Dr. Brad EliAnn McCulloch, MBA is co-founder and president of Orofacial Therapeutics, this site, and provides resources and tools for jaw and headache pain diagnosis and treatment. Her own experience with chronic jaw pain issues inspire her to investigate the healthcare needs and challenges of domestic abuse victims, such as how to find a TMJ provider.

 

References

[1] United Nations and partners, https://www.who.int/news-room/fact-sheets/detail/violence-against-women, March 9, 2021

[2] Gauer RL, Semidey MJ., Diagnosis and treatment of temporomandibular disorders, https://pubmed.ncbi.nlm.nih.gov/25822556/, March 2015

[3] Michele Runci Anastasi, et al, Articular Disc of a Human Temporomandibular Joint: Evaluation through Light Microscopy, Immunofluorescence and Scanning Electron Microscopy, https://www.mdpi.com/2411-5142/6/1/22, January 18, 2021

[4] Vanessa E. Miller, et al, Characteristics associated with high-impact pain in people with TMD: a cross-sectional study, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424335/, March 2019

[5] Takeuchi T, et al, Symptoms and physiological responses to prolonged, repeated, low-level tooth clenching in humans, https://pubmed.ncbi.nlm.nih.gov/25754714/, March 7, 2015

[6] Joht Chandan, et al from the University of Birmingham, Intimate partner violence and temporomandibular joint disorder, http://pure-oai.bham.ac.uk/ws/files/58690924/Intimate_partner_violence_and_temporomandibular_joint_disorder_AAM.pdf, 2019

[57] Ji RR, et al, Neuroinflammation and Central Sensitization in Chronic and Widespread Pain, https://pubmed.ncbi.nlm.nih.gov/29462012/, August 2018

[8] Koehler JL, Gauer RL. Otolaryngeal and Oropharyngeal Conditions: Temporomandibular Disorders, https://pubmed.ncbi.nlm.nih.gov/33595264/ February, 2021

[9] Sun T, et al, A deep dive into the static force transmission of the human masticatory system and its biomechanical effects on the temporomandibular joint, https://www.sciencedirect.com/science/article/abs/pii/S0169260723000032, 2023 Mar

[10] Lukic N, et al, Short-term effects of NTI-tss and Michigan splint on nocturnal jaw muscle activity: A pilot study, https://pubmed.ncbi.nlm.nih.gov/33369223/ Epub 2020 December 25, 2020

[11] Rebecca Garcia,et al, The Impact of the COVID-19 Pandemic on Intimate Partner Violence Advocates and Agencies, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8547898/, Updated 2022