Chapter 1
Introduction

In earlier civilizations, trepanization (drilling holes in the skull) was performed because of the belief that this would release demons that had entered into the skull and had to be released, if headache relief was to result. In the seventeenth century, it was suggested by Willis that the head pain of 'megrim' or migraine resulted from the swelling of blood vessels within the head. Interestingly, this explanation of blood vessel swelling is close to the belief today that such swelling is involved in migraine headaches (Edmeads, 1997). At the turn of the twentieth century, Sir William Osler proposed that headaches were due to 'muscular rheumatism' of the head. This was probably the first suggestion that muscle abnormalities might be involved. During the 1940s, Wolff carried out a series of experiments that showed that involuntary contraction of scalp and neck muscles could result in headache development. Other causes have been suggested; these were more serious than muscle dysfunction and would evidently require other medical interventions (Solomon, 1993).
In the worldwide view, headache can be such a big health problem as evidenced by the establishment of the World Headache Alliance in 1997. The organization exists to alleviate the burden of headache worldwide, in particular, by sharing information among headache organizations and by increasing the awareness and understanding of headache as a public health concern with profound social and economic impact. Worldwide, according to the World Health Organization (WHO), migraine alone is 19th among all causes of years lived with disability (YLDs). Headache disorders impose recognizable burden on sufferers including sometimes substantial personal suffering, impaired quality of life and financial cost. Repeated headache attacks, and often the constant fear of the next one, damage family life, social life and employment.
Background of the Study
Headache itself is a painful and often disabling feature of a relatively small number of primary headache disorders. It also occurs secondarily to a considerable number of other conditions (WHO, 2004).
Let us take in the case of chronic headache sufferers who experience bouts of headache almost every day of their lives or at least more than 15 days in a month. Headache for these people may be a lot to deal with as it consumes them resulting to frequent absences from work or school and slightly debilitating their ability to function. In these cases, it is imperative not only to lessen if not eliminate episodes of headache but to ultimately find the root cause of the headache.
It may be easy to link headache to neurological pathologies but as simple as it may seem, headache could build millions of cobwebs of differential diagnosis along with the expensive cost of diagnostic procedures and visits to medical consultations from medical specialists. With this thought in mind, the researcher would want to look into the possibility of an orthodontic origin of chronic headache.
In the literature, a person needs to start regularly visiting the dentist at the age of three but aside from the fact that money is such a scarce especially for the economy of the Philippines, there is this misconception that appointments to the dentist are nothing but only for aesthetic purposes that make these necessary checkups with the dentist the least priority. This is more so when the symptom that a person often complains about is quite far from getting a relief from a visit to the dentist, i.e. headache. It is but natural for a person to go and seek help from a medical doctor when experiencing chronic headache episodes. Yet, as it is already mentioned, a simple headache can branch out from much different pathology and complex ones we could imagine just like how headache can signify a problem in the alignment of the jaw and that is the temporomandibular joint disorder or TMJD. The researcher would like to study on the incidence of TMJD among chronic headache patients who have been seeking TMJ treatment in a dental clinic

Statement of the problem This study aims to determine the incidence of temporomandibular joint disorder among headache patients
Specifically seeks answers to the following questions: 1. What are the profiles of the respondents in terms of:
1.1 Age
1.2 Gender
1.3 Occupation
2. What are the common complaints of patients who seek dental consultation?
3. What is the frequency of headache episodes for these patients?
4. What are other symptoms experienced or has manifested in these patients?
5. What are the treatments given by the attending dentist?
6. What are the effective treatments which decreased the signs and symptoms?
7. Is there any significant difference in the frequency of TMJD when grouped according to: a. Age b. Gender c. Occupation

Hypothesis There is no significant difference in the frequency TMJD when grouped according to: (1) Age, (2) Gender, and (3) Occupation.
Theoretical framework This study is theoretically based on the Convergent-projection theory of referred pain by W.A. Sturge and J. Ross from 1888 and later TC Ruch in 1961. This theory proposes that nerves converge in the same spinal neuron in turn explaining why local pain and referred pain are simultaneous and at the same rate of intensity. In this study, we are anchoring headache as the pain that surfaces with jaw problem hence, the jaw being the site of local pain and the head as the site for referred pain.
Conceptual framework

Signs and symptoms of TMJD
Age, gender, occupation
Treatments effective for TMJD

Incidence of temporomandibular joint disorder

Conceptual Paradigm
Figure 1. In the conceptual paradigm, it is further explained the significant relationship of the respondents’ profile namely age, gender, and occupation to the incidence of temporomandibular joint disorder. Also, the study would like to determine significant difference among treatments effective for TMJD and signs & symptoms of TMJD against the same profile of the respondents.
Definition of Terms The following terminologies used in the study operationally:
Temporomandibular joint disorder (TMJD). Any derangement involving the jawline and its joint. Chronic headache. Episodes of headache that is experienced at least 15 days a month.
Patients. These are people who have been seeking TMJD treatments for the past six months in a dental facility.
Treatments. These are different modalities that helps improve the condition of a TMJ patient. These treatments include invasive and non invasive procedures such as surgical procedures and therapeutic exercises respectively, use of mouth appliance like mouth guards and splints, and pharmacologic regimen.
Age. Number of years from birth up until the present time.
Gender. Refers to biological sexual category.
Occupation. Refers to the employment of the respondents.

Significance of the study This study aims to determine the extent of the incidence of TMJ disorders among chronic headache sufferers.
The researcher foresees that the study will be beneficial to the following: Patients. The people who have been suffering from chronic headache will be spared of the expensive neurological imaging and examinations if less expensive TMJ evaluation will be a part in assessing headache. Establishing TMJ evaluation before venturing on expensive neurological diagnostic examinations will save the patient from spending good value of money as well as from the burden of going through treatment that will never give them comfort. Nurses. The study will help nurses be more familiarized with the condition. The researcher, having the disorder herself, would like to spread information about TMJ along with headache as its most common symptom. Thus, widen one’s capability in giving health awareness and education.
Medical doctors. This study is anchored with the goal to augment interventions in alleviating if not eliminate symptoms of headache to these patients by establishing TMJ evaluation as routine diagnostic examination. Dentists. The study having to prove the validity of TMJ evaluation as routine examination during diagnosis of a patient’s condition will lessen the burden of dentists in explaining how a seemingly neurological symptom such as headache can be of dental origin. Future researchers. After the conduction of this study, future researchers can base an experimental study on the relationship between headaches and/or one of the profiles of the respondents and the incidence of temporomandibular joint disorder.
Scope and Limitations The study will focus on the incidence of temporomandibular joint disorder among chronic headache patients. In selecting the samples for the study, those who are diagnosed to have TMJD by a licensed dentist and those who have been seeking treatment for TMJD for the past six months will be included.
The study will not aim to discern the specific type of headache which commonly affects a person with TMJD.

Chapter 2
Review of Related Literature
Headache
Headache may be considered as one most common complaint a person may have across his lifespan and perhaps a commonly overlooked symptom as well. A headache may be simply presented as pain around the area of head and neck and can be treated with analgesics available over the counter yet this is not always the case.
Although the epidemiology of headache disorders is only partly documented, taken together, headache disorders are extraordinarily common. Population-based studies have mostly focused on migraine which, although the most frequently studied, is not the most common headache disorder. Other types of headache, such as the more prevalent TTH and sub-types of the more disabling chronic daily headache, have received less attention. Few population-based studies exist for developing countries where limited funding and large and often rural populations, coupled with the low profile of headache disorders compared with other diseases, prevent the systematic collection of information.
In developed countries, Tension Type Headache (TTH) alone affects two-thirds of adult males and over 80% of females. Extrapolation from figures for migraine prevalence and attack incidence suggests that 3000 migraine attacks occur every day for each million of the general population. Less well recognized is the toll of chronic daily headache: up to one adult in 20 has headache nearly every day.
According to Abu-Arefeh and Russell (1994), the prevalence of chronic non-progressive (or chronic-daily) headache during adolescence is 0.2 to 0.9 percent. No specific diagnostic criteria have been established, although ongoing studies in children define chronic-non-progressive headaches as those lasting four or more hours and occurring 15 or more times a month for a period of four or more months. Many adolescents have continuous, unremitting daily headache.
Headache being one of the oldest human diseases, it is often overlooked and almost considered as a normal part of daily living. This consideration may be only made by those who occasionally suffer from headaches but is not the case for those who are crippled by the disease. In fact, from an online article, a 30 year old nurse once said, “When I have headache, I feel like a different person is living inside my body”. From these facts, it is only just to get wider options for those who are suffering from chronic headache and that is looking into the possibility of disarray in the TMJ as the root cause for these headaches.
Headaches have numerous causes, and in 2007 the International Headache Society agreed upon an updated classification system for headache. Because so many people suffer from headaches and because treatment sometimes is difficult, it is hoped that the new classification system will allow health care practitioners come to a specific diagnosis as to the type of headache and to provide better and more effective treatment.There are three major categories of headaches: (1) primary headaches, (2) secondary headaches, and (3) cranial neuralgias, facial pain, and other headaches.
Primary headaches can affect the quality of life. Some people have occasional headaches that resolve quickly while others are debilitated. While these headaches are not life-threatening, they may be associated with symptoms that can mimic strokes or intracerebral bleeding.
Primary headaches include migraine, tension, and cluster headaches, as well as a variety of other less common types of headache. Tension headaches are the most common type of primary headache. Up to 90% of adults have had or will have tension headaches. Tension headaches occur more commonly among women than men. Tension-type headache is a term that was used earlier to characterize what was previously considered to be a group of headache types. These included: (i) tension (ii) muscle contraction (iii) stress and (iv) ordinary headaches (Silberstein and Silberstein, 1990). These are grouped together as tension-type headaches and considered to be caused by prolonged muscle tension in the muscles of the face, neck and/or scalp (Simons and Mense, 1998).
Migraine headaches are the second most common type of primary headache. An estimated 28 million people in the United States (about 12% of the population) will experience a migraine headache. Migraine headaches affect children as well as adults. Before puberty, boys and girls are affected equally by migraine headaches, but after puberty, more women than men are affected. It is estimated that 6% of men and up to 18% of women will experience a migraine headache in their lifetime.
Cluster headaches are a rare type of primary headache affecting 0.1% of the population (1 in a 1,000 people). It more commonly affects men in their late 20s though women and children can also suffer these types of headache.
Secondary headaches are those that are due to an underlying structural problem in the head or neck. There are numerous causes of this type of headache ranging from bleeding in the brain, tumor, or meningitis and encephalitis.
The third category of headache referred to as cranial neuralgia, facial pain, and other headache are groups of headache that are caused by nerves in the head and upper neck that are inflamed and evolved to be the source of the pain in the head (Wedro, 2000).
Cranial neuralgia refers to pain originating in one or more of the cranial nerves. The twelve cranial nerves exit from the brain through openings in the skull to conduct sensory, motor and autonomic nerve impulses to and from the brain, face and head (Lee, 2011). Among these nerves, the trigeminal and glossopharyngeal nerves conduct sensory nerve impulses and can be subject to neuralgia. The precise location of the neuralgia symptoms depends on the nerve involved.
Temporomandibular Joint Disorder and its Causes The temporomandibular joint is the joint of the jaw also referred to as TMJ. This joint is between the head of the mandible and the mandibular fossa and the articular tubercle of the temporal bone. The TMJ allows the movement of the lower mandible whenever a person opens and closes his mouth and with this function, derangement in the TMJ is not uncommon as we thought it is. A micro trauma to the jaw caused by tooth grinding or bruxism, habitual clenching of the teeth, or even a simple faulty chewing, could harm the TMJ. In the same note, macro trauma such as punch or impact on the jaw could lead to TMJD. Aside from trauma, arthritis could also be a culprit of this condition as well as the wear and tear principle due to aging. Disorders of the teeth can contribute to TMJD such as loss of tooth causing misalignment of the occlusal surfaces. The temporomandibular joint (TMJ) is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet. Within the TMJ, there are moving parts that allow the upper jaw to close on the lower jaw. This joint is a typical sliding "ball and socket" that has a disc sandwiched between it. The TMJ is used throughout the day to move the jaw, especially in biting and chewing, talking, and yawning. It is one of the most frequently used joints of the body.
The temporomandibular joints are complex and are composed of muscles, tendons, and bones. Each component contributes to the smooth operation of the TMJ. When the muscles are relaxed and balanced and both jaw joints open and close comfortably, we are able to talk, chew, or yawn without pain.
We can locate the TMJ by putting a finger on the triangular structure in front of the ear. The finger is moved just slightly forward and pressed firmly while opening the jaw. The motion felt is from the TMJ. We can also feel the joint motion if we put a little finger against the inside front part of the ear canal. These maneuvers can cause considerable discomfort to a person who is experiencing TMJ difficulty, and doctors use them for making the diagnosis. Temporomandibular joint disorder gives a wide array of signs and symptoms that makes its diagnosis rather difficult. “The typical TMJ sufferer usually has headaches. Beyond this, it's impossible to be specific” (R. Goldman, 2008). From this insight of Dr. Goldman who has amassed thousands of hours of continuing education in the fields of occlusion, restorative and reconstructive dentistry and Temporomandibular Joint (TMJ) Dysfunction Syndrome, we can see how headache plays a critical role in the diagnosis of the said disorder.
TMJ syndrome, previously known as Costen’s syndrome after James B. Costen who first described the condition in the 1930s, presents a wide variety of symptoms which explains why TMJD is commonly defined as an umbrella term for acute or chronic inflammation of the joint concerned.
TMJ disorders are a group of complex problems of the jaw joint. TMJ disorders are also sometimes referred to as myofacial pain dysfunction and Costen's syndrome. Because muscles and joints work together, a problem with either one can lead to stiffness, headaches, ear pain, bite problems or malocclusion, clicking sounds, or locked jaws. The following are behaviors or conditions that can lead to TMJ disorders. Teeth grinding and teeth clenching (bruxism) increase the wear on the cartilage lining of the TMJ. Those who grind or clench their teeth may be unaware of this behavior unless they are told by someone observing this pattern while sleeping or by a dental professional noticing telltale signs of wear and tear on the teeth. Stress can contribute to the cause of teeth grinding ad clenching for people under stress tend to take out nervous energy into unconsciously or consciously grinding and clenching their teeth. Many patients awaken in the morning with jaw or ear pain. Habitual gum chewing or fingernail biting can also pose some trauma to the alignment of the jaw due to constant and often unguarded opening and closing of the mouth. Dental problems and misalignment of the teeth (malocclusion). Patients may complain that it is difficult to find a comfortable bite or that the way their teeth fit together has changed. Chewing on only one side of the jaw can lead to or be a result of TMJ problems. Previous fractures in the jaw or facial bones can also lead to TMJ disorders as in traumas. The joint is also damaged by a blow or other impact (Mayo Clinic, 2010). Occupational tasks such as holding the telephone between the head and shoulder may contribute to TMJ disorders. The TMJ could also be damaged when the disk erodes or moves out of its proper alignment and the joint's cartilage is damaged by arthritis.
TMJD as a cause of headache
Linking a neurological symptom such as headache to an orthodontic cause may be a long shot but it is noteworthy to consider that TMJD, a less known condition to people, is often signaled by constant headache that are commonly misdiagnosed with migraine or tension type headaches causing mistreatment failing to give comfort to the patient.
In human anatomy, nerves relay sensation from the point of its origin all the way to the brain through the dermatomes which is mainly supplied by a single spinal nerve. The human body has eight cranial nerves and all of these nerves feed the brain with sensation and it includes pain. One of these nerves is the trigeminal nerve that is responsible for all the sensation we feel in the face, tongue, sinus, palate, eyes, teeth, lips, and the jaw. The involvement of the nerves in the jaw then sends sensation of pain from the trigeminal nerves affecting other organs innervating in this nerve including some parts of the head which cause bouts of headache.
At the entire nervous system, only about 20% of the input to the brain comes from the spinal column. The other 80% comes from twelve sets of cranial nerves that control taste, smell, hearing, vision and eye movement, inner ear proprioceptive function and autonomic control of the organs and blood vessels of the body. 70% of that 80% (cranial nerves) or more than half of the total input to our brain comes from the trigeminal nerve. With so much neural input it must go to some very important structures.
The temporomandibular joint and the trigeminal nerves are some of the most important structures of the face. When the TMJ is out of alignment or compromised in other ways, it can affect many other areas of the head and neck. Because the trigeminal nerve, which innervates the TMJ, also innervates so much of the face and neck, pain all over the head and face may result when there is any sort of disorder in this important structure.
The scientific literature contains many studies indicating that headache is a frequent pain symptom associated with TMD (Segu, et.al., 1999). Cooper and Kleinberg (2007) reported that 79% of 4,528 patients presenting at a dental office for the treatment of TMD complained of headaches.
Trejo and Michael (1997) compared patients presenting at a headache clinic to those presenting to a TMD practice. They found that 73% of the TMD patients reported experience of having a headache and 60% of headache patients reported TMD symptoms. One literature review found as many as 70% of the TMD population presented with recurrent headaches (Major and Nebbe, 1997).
Ekberg, et al. (2006) found in 60 patients who reported for TMD treatment that a high percentage (76-83%) had headaches once a week or more. In a review of 425 TMD patients, Esposito, et al. (2000) found that 78% of TMD patients reported having headaches. A study conducted by Bloch et. al (1995) where temporomandibular joint symptoms in a randomly selected population of children, ages 3-16, found that headache was the most frequently reported pain symptom (52.2%). DePavia, et al. (2007) evaluated pediatric patients with headaches and reported a significant increase in signs and symptoms of TMD when compared to controls. They also indicated a significant increase in TMD signs and symptoms with age and emotional state (tense > calm). A study done in 2008 by V. Ballegaard, et. al. investigated on the overlaps of headache and TMJ disorder to describe its prevalence among headache patients. As a result, a percentage of 56.1% of the headache population were diagnosed to have TMJ disorder where those who have combined migraine and tension type headache dominated the portion of the percentage. Migraine and tension headache are well known types of headache that affect number of people. Medical researchers estimate that at least 20% of the population suffers from daily, or weekly, headache and common migraine (Halmaghi, 2010). Migraine and tension type headache sufferers or those with combined of these types may present a long history of headache episodes along with other symptoms such as nausea, vomiting, and sensitivity to light and noise. However, some medical practioners refuse to just resort on the diagnosis of migraine or tension headache stating that this will mean letting the patient be debilitated by bouts of headache and possible abuse of analgesic and other pain alleviating medications. Constantly strained and contracted muscles in the head, face, and neck cause migraine attacks and tension type headache. This strained and contracted muscles on the other hand are often brought about by the misalignment of the TMJ. The strained muscles in your head, face, and neck can cause headaches or TMJ migraines. TMJ headaches are often so painful, severe, and frequent that they are misdiagnosed as migraines (Pavlenko, 2004).
The association of migraine headache to the diagnosis of TMJ disorder has been put to test by one research study entitled “Use of the ID Migraine Questionnaire for Migraine in TMJ and Orofacial Pain Clinic” (Kim, S. & Kim C., 2006). The study aimed to determine if the ID migraine questionnaires can be utilized for assessment of migraine patients in TMJ and orofacial clinic. The ID Migraine questionnaire, which is a three-item screener consisting of nausea, photophobia, and headache-related disability, could be used as a self-administered report for detecting migraine headaches in patients with temporomandibular disorders and orofacial pain. In the study, it was not the TMJ disorder was not diagnosed based on headache but the other way around. The study revealed that a person with TMJ disorder would most likely to suffer from migraine headache at the same time.
When the muscles in your face, head, and neck are strained as in what happens when there is a misalignment in the TMJ, they prevent blood from flowing to the correct places. When this happens, the body attempts to correct the problem by sending more blood to the area, which increases blood pressure. This can cause a very painful feeling of pressure around the head, called a vascular headache (Pavlenko, 2004). Vascular headache which is another type of headache as we can see may have originated from disrupt in the hemodynamic processes of the body i.e. circulation of blood throughout the body yet, this disruption arose from the joint of the jaw being misaligned.
Temporomandibular joint disorder may be something that is new for a significant number of people but surprisingly, there has been number of studies that concerns about the disorder and its relativity to headache as the presenting symptom. Dating back from the late 1980’s, an article from Headache: The Journal of Face and Head Pain featured a study conducted by Schellhas, et. al. which concluded that out of 100 patients 64 complained of headache and facial pain were properly diagnosed to have TMJ disorder.
TMJD as a condition with a wide array of signs and symptoms
Other than chronic episodes of headache, there are many other symptoms that are seen from people with TMJD. This array of signs and symptoms includes discomfort to the area of the jaw like limited opening of the mouth, clicking or popping sounds upon opening and closing the mouth, deviation of the jaw to one side when opening the mouth, inability to find the correct bite. Also, there are number of teeth and gum problems which includes tooth clenching and grinding at night (bruxism), and sensitive teeth.
Some people with TMJD also experience some ear pain and ear problems i.e. hissing, buzzing, ringing, or roaring sounds. About 10% of all patients who come to ENT specialists with ear symptoms don’t actually have an ear related reason? In almost 100% of these patients - those with ear pain or other ear symptoms but whose ears are normal - the symptoms come from TMD (Beuerlein, 2011). Dr. Prabu Raman of The Raman Center for Headache and Jaw Pain Treatment (2011) explained that TMJD has been referred to as ‘the great impostor’ because a TMJ disorder may mask a whole different illness.
When the ear aches inside, most patients conclude that it is an ear infection and go see their primary physician or ENT specialist. If an otoscopic examination is normal, the source of the ear pain could be TMD. As discussed above the muscles that are associated with the ear are mostly controlled by the Trigeminal nerve. Poor alignment of the jaw can lead to spasm of any of these muscles leading to “ear pain”. So instead of prescribing an antibiotic as a shot gun treatment for this phantom ear infection, a TMD evaluation is appropriate.
While the Eighth cranial nerve enables hearing, one of the sensory branches of the Fifth cranial nerve – Trigeminal innervates the middle ear leading to the referred pain.
Another way TMD gives rise to ear pain is due to the remnants of Pinto’s ligaments that connected the posterior portion of the glenoid fossa (the socket of the TM Joint) to the middle ear. In TMD, the condylar head is often posteriorized – pushed backwards - leading to increased pressure in this area causing ear pain. Ears can feel stuffy and congested when the Eustachian tube is blocked. This can happen with swelling and inflammation as when there is an infection. It can also happen when the tiny muscle that controls the opening – called Tensor veli palatini is in spasm. When the jaw alignment is poor, the muscles of mastication and associated posture muscles have to compensate. This constant compensation can lead to muscles spasms and trigger points. By neuromuscularly correcting the jaw relation often leads to the resolution of the various symptoms including ear symptoms from this cause.
Ringing and roaring noise in the ears may be from several causes. Loud noise, clogging of the external auditory canal with ear wax, inflammation of the ear drum, over dose of medications such as Aspirin are all possible sources of tinnitus. But a large number of cases are due to TMD.
Tinnitus arises from the traction on the malleus by Pinto's ligament (disco-malleolar ligament) and/or associated musculature to the ear and Eustachian tube (tensor tympani and tensor veli palatini from throat) as well as other triggers particularly medial Pterygoid muscle. These triggers must be released. Tensor tympani is a tiny middle ear muscle that is attached to the malleus. When contracted, the tension is increased on the tympanic membrane. Its nerve supply is from the Mandibular nerve, a branch of the Trigeminal Nerve (fifth Cranial Nerve). Pinto’s ligament connects the articular disc of the TM Joint to the malleus bone of the ear.
Some may have throat problems such as swallowing difficulties, sore throat without any evidence of infection. Severe stabbing pain located in the back of the nose, throat or tongue can be a symptom of glossopharyngeal neuralgia, warns the New York Times Health Guide. The glossopharyngeal nerve is the ninth cranial nerve, and it functions in providing motor nerve impulses to a muscle called the stylopharyngeus. It also provides parasympathetic nerve impulses to the parotid glands in the cheeks and provides special sensory detection from the taste buds at the back of the tongue. The glossopharyngeal nerve also provides for the detection of sensory input from the lining of the pharynx, middle ear and back of the tongue, the same areas affected when the pain of glossopharyngeal neuralgia strikes. This type of neuralgia follows the same principle as trigeminal nerve innervations to the face, neck, head, and temporomandibular joint thus, making throat problems another symptom for TMJD.
There may also be ophthalmological problems such as blurring of vision due to the compression of the trigeminal nerve brought about by the inflammation of the jaw. Instances of short, shock-like episodes of intense sharp pain in the eye, cheek or lower half of the face are sometimes an indicator of trigeminal neuralgia. The trigeminal nerve is the fifth cranial nerve, and its functions include conducting sensory impulses to the face, mouth and sinuses as well as motor control of the muscles involved in chewing.
Once the disease has progressed into a more advanced stage, some patients may report shoulder or neck pain, stiffness, arm numbness and tingling sensations. According to Reilly (2006), The bones of the human head are directly associated with two of the body's most complicated joint systems, the cranial sutures of the skull and the (temporalmandibular joint). The human head sits atop the cervical structure with the center of gravity in front of the spine, linked by the musculature and joints. The function of the head posture when moving or at rest is dependent on the proper alignment of these muscles and joints. Depending on the degree, misalignment of any of these muscles or joints can translate into further stresses elsewhere in the structure.
Some of these symptoms, if not all, are felt by some patients but tend to ignore them or rather having the wrong treatment for these symptoms are not specific TMJD. Some may have even sought medical advice to specialists who does not actually believe in the existence of the disease itself. This skepticism is maybe because of the generality of the symptoms the disease can bring and it is only right to look into other medical reasons. Also, we may not see the deviation of the jaw with these patients unless the disease is already profound.
Diagnosis of TMJD
The exact causes and symptoms of TMD are not clear, diagnosing these disorders can be confusing. At present, there is no widely accepted, standard diagnostic test to identify all TMJ disorders. Because the exact causes and symptoms are not clear, identifying these disorders can be difficult and confusing. The American Association for Dental Research recommends that a diagnosis of TM disorders or related orofacial pain conditions should be based primarily on information obtained from the patient’s history and a clinical examination of the head and neck. In about 90 percent of cases, however, the patient's description of symptoms, combined with a simple physical examination of the face and jaw, provides information useful for diagnosing these disorders. Physical Examination is one key in diagnosing TMJD. The physical examination includes (1) feeling the jaw joints and chewing muscles for pain or tenderness, (2) listening for clicking, popping or grating sounds during jaw movement, (3) examining for limited motion or locking of the jaw while opening or closing the mouth.
Checking the patient's dental and medical history is very important. In most cases, this evaluation provides enough information to locate the pain or jaw problem, to make a diagnosis, and to start treatment to relieve pain or jaw locking.
Diagnostic tests are also very much valuable in diagnosing TMJD. Regular dental X-rays and TMJ x-rays (transcranial radiographs) are not generally useful in diagnosing TMD. Other x-ray techniques are usually needed only when the practitioner strongly suspects a condition such as arthritis or when significant pain persists over time and symptoms do not improve with treatment. These include: (1) arthrography (joint x-rays using dye), (2) magnetic resonance imaging (MRI), this provides images of the disc as well as the muscles and other soft tissues surrounding the joint., (3) tomography (a special type of x-ray), this provides greater detail of the bone but a somewhat limited view of the disc and soft tissues. It is indicated when a screening radiograph of the TM joint shows some bony changes. (4) Scintigraphy (Bone scan), this involves the injection of a radioactive substance that is absorbed by the bone cells and shows whether a pathologic process is in an active or inactive state.
Treatment for TMJD Some medical experts say that TMJ disorders may heal without doing anything about it and just let the signs and symptoms pass. The signs and symptoms may disappear without any treatment but for some people whose signs and symptoms may be too much to bear, there are varieties of treatment options they can choose from the less invasive ones like therapeutic exercises up to surgical interventions. Becoming more aware of tension-related habits — clenching your jaw, grinding your teeth or chewing pencils — will help you reduce their frequency (Mayo Clinic, 2011). A person with TMJD may start with lifestyle changes and some home remedies. One may start by avoiding overuse of jaw muscles so that there will be minimal strain on the jaw muscles. There will be less work on the jaw muscles by doing the following, (1) Eating soft foods, (2) cutting food into small pieces, (3) avoiding sticky or chewy food and chewing gum, and (4) refraining from opening the mouth too wide during yawns.
Stretching and massage can also be beneficial to improve head, neck and shoulder posture. The doctor or dentist may show how to do exercises that stretch jaw muscles and how to massage the muscles (Mayo Clinic, 2011).
One is jaw straightening which is done by Standing in front of a mirror and slowly open your mouth, carefully observing how each side of the jaw is functioning. Then, open the mouth again, this time focusing on manipulating the jaw to force it to open straight, or evenly on both sides. This exercise helps strengthen the muscles on the weakened or affected side of the jaw. Open and close your mouth 10 times and then rest for a few minutes. You may repeat this exercise two to three times several times a day for strengthening.
Another one is stretching for strength that is done by Opening your mouth as far as you can without causing pain. Very slowly and gently, place the fingers of one hand between the teeth on your upper and lower jaw and try to open your mouth a little more. Do not force the mouth to open much further, but a little bit at a time to allow the muscles in the jaw joint to slowly stretch and strengthen over time. The Atlanta Dental Group suggests placing a warm washcloth on the jaw in between these exercises to help flood the area with oxygen and nutrient-enriched blood for muscle strength, endurance and function.
Chin Tucks is also recommended which can be done to Strengthen the muscle groups surrounding and supporting the jaw structure by performing chin tucks, suggests the Nicholas Institute of Sports Medicine and Athletic Trauma. Sit or stand with your back straight, shoulders pulled back and chin parallel to the floor. Thrust the chin forward, still keeping your head straight. Place the fingers of your right hand on your chin and force your head back while resisting the move with your muscles. Perform this exercise between 10 and 15 times several times a day. Jaw Thrust relaxes your jaws so that your teeth are slightly separated and relaxed, suggests the Abbott Center for Neuromuscular Therapy website. Push your lower jaw forward while exhaling, so that your lower teeth extend beyond the upper teeth. Only go as far as you can without pain. Hold that position for several seconds and then relax. Repeat this exercise between five and 10 times.
If exercises do not suffice, there are home remedies that a person can resort to. Applying warm, moist heat or ice to the side of the face may help relax your muscles or alleviate pain (Mayo Clinic, 2011). Home therapy includes mandible (lower jaw) movements, such as opening and closing the jaw from side to side. Try this after a warm compress is applied for 20 minutes. The lower jaw movements should be repeated three to five times a day, five minutes continuously each time, for about two to four weeks. A gentle massage of the area can also be beneficial.
TMJD can pose a pain that a person can experience and pain medications are just on top of the list when it comes to medications commonly given to these patients. OTC, or over-the-counter, medications such as Tylenol and Advil are the most common medications given by doctors treating TMJ. This is because there is no chance for an individual to develop dependency on the drug and is often useful in treating the pain associated with TMJ. When it comes to painkillers, over the counter drug may not be enough and the doctors may recommend stronger ones. Painkillers, such as Percocet, Vicodin or Oxycodone, are narcotic medications that are used to treat moderate to severe pain. These painkillers are opiates that affect the brain to relieve pain, according to Theantidrug.com. Painkillers are to be used for a short time only, because they lead to dependence and withdrawal symptoms when not taken.
Also, since TMJD is also muscular in nature, muscle relaxants are also used in pharmacologic therapy. Muscle relaxants are medications given to relax the muscles surrounding the jaw that tend to become tight when one has TMJ. Examples of commonly prescribed muscle relaxants are Flexyrl and Skelaxin. According to muscle-relaxers.org, they affect the body's central nervous system and relax the muscle in question to allow it to heal. NSAIDs, or Nonsteroidal Anti-inflammatory Drugs, are used to treat the inflammation of the jaw muscles and surrounding tissues, according to MedicineNet. They also are used to treat mild to moderate pain. Examples of NSAIDs are Celebrex and Naproxen. Unlike painkillers, they do not lead to dependence, but are not as strong in treating pain. Mouth appliances are also one of the options for TMJD treatment. These appliances include splint or commonly called bite guards.
The splint is made out of plastic and is fabricated to fit inside the upper teeth. It looks like an orthodontic retainer without the wire going across the outside of the front teeth. This splint is designed in such a way that when the patients put their teeth together, the lower front teeth touch the front part of the appliance and the back teeth are held slightly apart. This prevents the back teeth from gearing together and, in effect, keeps the teeth apart without conscious effort. This instantly eliminates the tooth-gearing problem.
The splint is necessary to remove the triggering mechanisms that program the neuromuscular system to keep the jaw in an abnormal position. Remember that without this abnormal "program" the jaw knows where it wants to go. The muscles, through the reflex mechanism, have programmed the jaw to go into a position that, on the surface, tends to protect the teeth, the jaw, and the temporomandibular joint. But in reality this protective position may send the muscles into spasm. The object of the splint is to allow the jaw to go back to its normal relaxed position. It doesn't do this all at once, but gradually in progressive stages.
Only the front teeth contact the splint. This is done for two reasons. During treatment the jaw is repositioning itself. The splint itself creates an interference in this process, and the farther away the splint is from the joints the less effect the interference will have.
The other reason for this splint design involves the practicality of treatment time and the number of days between visits. No splint can be perfectly adjusted, and throughout Phase I treatment, the jaw is constantly moving in response to the splint. The back teeth aren't involved in the splint because the complexity of their gearing with the splint would make it almost impossible to adjust properly. If treatment progresses at all, it progresses more slowly.
Surgery has often been called “the cry of defeat.” When all else fails, removal or rearrangement of the parts offers a last opportunity to resolve the problem. However, until such time as there is a better understanding of the etiology of the various disease processes that affect the human body, and medical interventions can be used to prevent or treat these conditions, surgery still represents a viable alternative. This is true in the temporomandibular joint (TMJ) as well as in other regions of the body. A review of the literature, however, indicates that surgery of the temporomandibular joint for the management of conditions causing chronic pain has a history of varied and unpredictable results. Because such forms of surgery are commonly used, it is important to understand the reasons for this unreliability so that efforts can be made to improve the utility of these procedures.
The most common reason for unsuccessful TMJ surgery is a failure to eliminate the underlying cause of the problem in addition to the obvious pathology. Too often, the surgeon deals only with the immediate situation and fails to consider what initially led to its development. Unless the latter is done, there is a great risk of the same factors leading to a recurrence of the condition.
Another common reason why TMJ surgery may be unsuccessful is the establishment of a wrong preoperative diagnosis. Because of the similarity in signs and symptoms between patients with masticatory muscle pain and dysfunction (MPD) and those with certain diseases of the TMJ, as well as because of the frequent etiologic interrelationship between muscle and joint problems, TMJ surgery is often done for persons with primarily a myofascial pain problem. On the other hand, a correct diagnosis can be made, but the patient may be inappropriately treated with surgery when medical management is actually indicated. Moreover, even when surgery is indicated, and the appropriate operation is done, insufficient attention to proper postoperative care and rehabilitation can still lead to a less than satisfactory outcome.
When all of the factors that can contribute to the varied and unpredictable results withTMJ surgery are considered, two things become apparent: first, that improper diagnosis is a key factor, and second, that when surgery is used, it is essential to understand which conditions are amenable to operation, when it should be done, and what can be accomplished.
There are many pathologic conditions involving the temporomandibular joint. These include congenital and developmental anomalies, traumatic injuries, various forms of arthritis, neoplastic disease, and internal derangements. However, only the arthritides and the internal derangements commonly give rise to chronic TMJ pain.
The TMJ is subject to all of the forms of arthritis that affect other joints in the body. Thus, in addition to the commonly encountered cases of rheumatoid and degenerative arthritis, one may see patients with rheumatoid variants (psoriatic arthritis and ankylosing spondylitis), infectious arthritis, posttraumatic arthritis, and metabolic arthritis (gout and pseudogout).
Synthesis
Headache may be considered as an organic condition that most people must have suffered from at one point of their lives and has become a common complaint heard may it be the hospital, school, or place of work. Some may even see headache as another overrated symptom that would only need pain relievers but that will not always be the case. A headache we often regard as simple and easy to treat may be a sign of a far more serious underlying condition. As for the researcher, a headache that is not alleviated by pain relievers should be carefully looked at and evaluated. As simple as a headache may seem, diagnosing its root cause can be quite tough and would tend to become costly in the long run. In the literatures presented, it can be safe to say that the association of headache to temporomandibular joint disorder is of high probability.
Temporomandibular joint disorder is a condition some people suffer from that most of us are not aware of. A disease with a variety of signs and symptoms like TMJD can be hard to diagnose considering how this part of the human anatomy is often overlooked in spite of its very important function in our daily lives such as talking and chewing.
Having headache as the most common complaint and a long list more of signs and symptoms that equates to TMJ disorder can be downright hard to diagnose and often mistaken for another disease. If only evaluation for TMJD will become routine, costly and ineffective diagnostic procedures and treatments will prevent the burden of patients who have already been suffering. This study will give its readers an overview of what is the temporomandibular joint, how headache can tell an underlying disease that we never thought it could, and why headache can signal a temporomandibular joint disorder.
Headache being a very generic symptom and temporomandibular joint disorder as an overlooked disease is a combination that is worth looking an in depth manner as in a research study.

Chapter 3
Research Methodology Research Design This study will rest on a quantitative research design where systematic empirical investigation of social phenomena via statistical, mathematical or computational techniques (Given, 2008). The study will specifically use non experimental descriptive correlational research which aims at investigating the existence and the degree of relationship between two or more quantitative variables. The purpose of descriptive correlational research design is to understand relationship between variables (Polit and Beck, 2003). The researcher aims to describe the relationship of chronic headache episodes along with other symptoms and the respondents’ profile so it is only rationale to utilize descriptive correlational type of research. Participants The respondents will be selected using non-random sampling technique. Purposive sampling with the unique criteria: 1. Those who are diagnosed to have TMJD by a licensed medical practitioner. 2. Those who have been seeking TMJD treatment for the past six months. Setting The researcher will be getting participants for the study in various dental clinics around Metro Manila which caters for TMJ patients and the ones with dentists who are trained to diagnose and treat temporomandibular joint disorders.

Instrumentation The researcher will come up with a self made questionnaire which will be given to respondents to answer which will be consisting of four different parts.
The first part will be profiling of the respondents where they will be asked of their age, gender, and occupation. The second part will ask the respondents of the frequency of their headache episodes. The third part will be about the common complaints which prompted the patients to seek dental consultation. The fourth part will be about the treatments the patients have gone or are currently going through and which of these treatments are or have been effective in the improvement of the signs and symptoms of TMJD will be on part five of the questionnaire.
Procedures
The researcher will be asking for an approval on the conduction of the study. Once the administrative clearance from the Graduate School of Nursing Concordia College is granted, the researcher will proceed to asking permission from respective authorities of medical institutions where the study will be conducted. The researcher projects a time frame of one month for the conduction of the study. The first week will serve as the preparation phase which includes the coordination to respective dental clinics where the participants will be coming from. Two weeks will be devoted for the implementation phase of the study. During this phase, the researcher will distribute and collect the questionnaires from the respondents. The final week will be utilized for the statistical treatments of the date collected from the questionnaires along with its interpretation and analysis.
The researcher will be asking at least three orthodontists who are specializing in the treatment of temporomandibular joint disorders to validate the self made questionnaire which will be utilized during the implementation phase and data gathering of the study. A pilot study that will include ten respondents will be also be made before the actual conduction of the study. After the conduction of the study, data gathered from respondents will then be subjected to statistical treatments.
Data Analysis The study will be using the following statistical treatment:
1. Cronbach Alpha: A test to measure internal consistency and reliability. This will be utilized in the conduction of pilot study.
2. Frequency and Percentage: This will be specifically used in describing the following: (1) Profile of the respondents; (2) Number of headache episodes; (3) Complaints, signs, and symptoms experienced by the patients; (5) Treatments the patients have undergone; and (7) Treatments which are effective. 3. Chi square: This will be used in testing the null hypothesis
4. ANOVA: This will be utilized in testing how significant is the difference among means of 3 or more sets of data. Data that will be tested under Chi Square and ANOVA are the test of significant difference for the profile of the respondents which are age, gender, and occupation.

Limitations The researcher will only include patients who have been diagnosed to have TMJD by dental doctors and those who have been seeking treatment for the past six months at the time of the conduction of the study. The study will focus on the association of headache and the incidence of TMJD along with its difference when profile is taken into consideration.

REFERENCES A. Books Brunner L. and Suddarth D. 11th edition (2008). Textbook of Medical-Surgical Nursing. Lippincott Williams and Wilkins. Polit and Beck, 7th edition. (2009). Nursing Research Principles and Methods. Lippincott Williams and Wilkins.

B. Electronic Database Abu-Arefeh I and Russell G. (1994). Prevalence of headache and migraine in schoolchildren. BMJ, 309, 765–9 from www.ncbi.nlm.nih.gov/pubmed Agerberg and Wanman (1986). Headache and Dysfunction of the Masticatory System in Adolescents. Cephalalgia,6 (4), 247-255. doi: 10.1046/j.1468-2982.1986.0604247.x
Ballegaard, V. et. al. (2008). Are headache and temporomandibular disorders related? A blinded study. Cephalalgia, 28 (8), 832-841 from www.onlinelibrary.wiley.com

Cooper, B. and Kleinberg, I. (2009). Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment, 27 (2) from http://www.freepatentsonline.com
Forssell, H. et. al. (2002). Changes in Headache After Treatment of Mandibular Dysfunction. doi: 10.1046/j.1468-2982.1985.0504229.x
Glaros, A. et. al. (2007). Headache and temporomandibular disorders: evidence for diagnostic and behavioural overlap. Cephalalgia, 27 (6), 542-549. DOI: 10.1111/j.1468-2982.2007.01325.x Goncalves, D. et. al. (2010). Headache and Symptoms of Temporomandibular Disorder: An Epidemiological Study, 50 (2), 231-241. DOI: 10.1111/j.1526-4610.2009.01511.x Haley, D. et. al. (2005). The Comparison of Patients Suffering from Temporo-mandibular Disorders and a General Headache Population. DOI: 10.1111/j.1526-4610.1993.hed33040210.x Kim, S. and Kim, C. (2006). Use of the ID Migraine Questionnaire for Migraine in TMJ and Orofacial Pain Clinic. Headache: The Journal of Head and Face Pain, 46 (2), 253-258 from www.onlinelibrary.wiley.com

Morgini, F. et. al. (2000). Personality characteristics and accompanying symptoms in temporomandibular joint dysfunction, headache, and facial pain. Journal of Orofacial Pain, 14 (1), 52-8 from www.onlinelibrary.wiley.com

Mongini, F (2007). Current Pain and Headache Reports, 11(6), 465-70] DOI: 10.1007/s11916-007-0235-z Nilner, M. and Henrikson, T. (2000). Temporomandibular disorders and the need for stomatognathic treatment in orthodontically treated and untreated girls. doi: 10.1093/ejo/22.3.283

Rantala, M. et. al. (2003). Temporomandibular joint related painless symptoms, orofacial pain, neck pain, headache, and psychosocial factors among non-patients, 61 (4), 217-222. doi:10.1080/00016350310004089

Schellhas, K. et.al. (2005). Facial Pain, Headache, and Temporomandibular Joint Inflammation Headache: The Journal of Head and Face Pain, 29 (4), 229-232 from www.onlinelibrary.wiley.com Sillanpaa, M. et. al. (1991). Prevalence of headache at preschool age in an unselected child population. Cephalalgia, 11, 239–42 from www.ncbi.nlm.nih.gov/pubmed

Appendix A Survey Questionnaire

Name (optional): ______________________________________________________
Part I. Profiling Age: Gender: Occupation:
Part II. Frequency of headache How frequent do you experience headache? Please tick on the appropriate box. Everyday 1-3 days a week 4-6 days a week Others/Please specify: __________________________________________________
Part III. What are the symptoms that prompted your medical/dental consultation? Please tick on all that applies to you. Swallowing difficulties Ear pain Limited opening of mouth Tooth clenching Lock jaw Sensitive teeth Ringing in the ears Shoulder pain Headache Neck stiffness/numbness Sharp eye pains Arm numbness Teeth grinding at night (bruxism) Tingling sensation Sore throat Facial pain Uneven/uncomfortable bite Pain in the jaw Others/Please specify: ____________________________________________________________________ Part IV. What are the treatments that you have gone through? Therapeutic exercises Pain medications Oral appliances Surgery Part V. What are the treatments that have been beneficial to you? Therapeutic exercises/Please specify:________________________________________________________ Pain medications/Please specify:____________________________________________________________ Oral appliance/Please specify:______________________________________________________________ Surgery/Please specify:___________________________________________________________________ Appendix B Letters Administrative clearance from Concordia College, Graduate School of Nursing to conduct the study Cyruz P. Tuppal RN, RM, RT, MSN, MASPED, DMS, DNSc
Program Coordinator
Concordia College, Graduate School of Nursing Pedro Gil, Metro Manila

Dear Dr. Tuppal, Greetings of Peace! I am Bianca Camille D. Cabrera, a graduate student of your reputable institution taking up Master of Science in Nursing major in Medical-Surgical Nursing. In connection to this, for the completion of the degree, I would like to humbly ask for your permission to conduct my study entitled, “Incidence of Temporomandibular Joint Disorder Among Chronic Headache Patients”. Thank you very much for your kind consideration with regards to this matter. God bless!

Sincerely, Bianca Camille D. Cabrera, RN MSN Candidate

Noted by: Mr. Arnold M. Maniebo, RN, MSN Thesis Adviser

Cyruz P. Tuppal
RN, RM, RT, MSN, MASPED, DMS, DNSc MSN Coordinator

Administrative Letter to the Dental Clinics

Dentist
Name of the clinic
Address

Dear sir/madam,
Greetings!
I, Bianca Camille D. Cabrera, am currently conducting a research study entitled “Incidence of Temporomandibular Joint Disorder Among Chronic Headache Patients” as a requirement in the fulfillment of my degree of Master of Science in Nursing. In line with this, I would like to humbly ask for your permission to set your clinic as one of the study’s locale. I will need to ask patients of your clinic to answer the attached questionnaire and be confident that their participation will be kept in an utmost confidentiality.

Please be rest assured that information that will come up from this study will solely be used in a scholastic manner and intent.
Thank you very much for your kind consideration regarding this matter. Sincerely,

Bianca Camille D. Cabrera, RN
MSN Candidate

Noted by: Mr. Arnold M. Maniebo, RN, MSN Thesis Adviser

Cyruz P. Tuppal
RN, RM, RT, MSN, MASPED, DMS, DNSc
MSN Coordinator

Letter to the Respondents

Dear sir/madam,
Greetings!
I, Bianca Camille D. Cabrera, am currently conducting a research study entitled “Incidence of Temporomandibular Joint Disorder Among Chronic Headache Patients” as a requirement in the fulfillment of my degree of Master of Science in Nursing. In line with this, I would like to humbly ask for your permission to be one of my participants of the said study.
Please be rest assured that information that will come up from this study will solely be used in a scholastic manner and intent and be treated with utmost confidentiality.
Thank you very much for your kind consideration regarding this matter. Sincerely,

Bianca Camille D. Cabrera, RN
MSN Candidate

Noted by: Mr. Arnold M. Maniebo, RN, MSN Thesis Adviser

Cyruz P. Tuppal
RN, RM, RT, MSN, MASPED, DMS, DNSc
MSN Coordinator

Letter to the Experts on Temporomandibular Joint Disorder

Name of the dentist

Dear Sir/Madam, Greetings of peace! I am Bianca Camille D. Cabrera, a graduate student of your reputable institution taking up Master of Science in Nursing major in Medical-Surgical Nursing. For the completion of my degree, I am currently conducting my study entitled, “Incidence of Temporomandibular Joint Disorder Among Chronic Headache Patients”. In connection to this, I would like to humbly ask for your expertise on the validation of the survey questionnaire for the said study. Thank you very much and God bless!

Sincerely, Bianca Camille D. Cabrera, RN MSN Candidate

Noted by: Mr. Arnold M. Maniebo, RN, MSN Thesis Adviser

Cyruz P. Tuppal
RN, RM, RT, MSN, MASPED, DMS, DNSc MSN Coordinator