Tinnitus, vertigo, and temporomandibular disorders

William S. Parker, DMD, PhD, a and Richard A. Chole, MD, PhD b

Davis, Calif.

Although tinnitus and vertigo have been reported as associated with temporomandibular disorders
(TMD) for many years, no control studies have been reported. This study was designed to include
two large control populations, as well as a large TMD sample. The null hypothesis was tested. The
results revealed that tinnitus and vertigo were significantly more prevalent in the TMD group than
in either control group. Reasons for the association of TMD and these otologic symptoms have
been proposed and they are discussed. Presently the cause is unknown. (AM J ORTHODDENTOFAC
ORTHOP 1995; 107:153-8.)

G o o d f r i e n d , an American dentist, is of- necessarily imply a causal relationship. Many pre-

ten credited as the first (1933) to report a relation-
ship between otologic symptoms and the temporo-
mandibular articulation. However, Monson 2 and
Wright, 3 both dentists, described deafness related
to the position of the mandible and the temporo-
mandibular joint in 1920. Decker 4 a physician, in
1925 reported a series of cases of deafness with
hearing loss and closed bites that responded to
dental treatment. Others 5-23 have continued to
comment. Different mechanisms have been postu-
lated to account for these phenomena. 24-33 As dif-
ferent scenarios have been proposed, various
names have been offered. Although Costen's Syn-
drome 5 pays tribute to the author, many of the
names describe the problem as viewed by the
proponents of that title. Thus, "temporomandibu-
far joint pain syndrome" was proposed by Schwartz
and his associates 33 who were among the first to
recognize the multiple possible causes. Because
Laskin34 and his group believe that most of the
problems are not in the joint itself, they suggest
"myofacial pain dysfunction syndrome." BelP 5 pre-
fers craniomandibular syndrome," providing a
blanket term. The American Dental Association
sponsored conference reported by McNeili et al? ~
suggested "temporomandibular disorders." There
are, in fact, many other suggested names.
Although tinnitus, dizziness, and vertigo are
common complaints in the general population, the
occurrence of these symptoms in patients with
temporomandibular disorders (TMD) does not
From the Department of Otolaryngology, School of Medicine, University
of California, Davis.
~Clinical Professor.
UChairman and Professor.
Copyright © 1995 by the American Association of Orthodontists.
0889-5406/95/$3.00 + 0 8/1/51157
vious studies have found otologic symptoms in
patients with TMD to be much more frequent than
in so-called normal populations. However. we have
been unable to identify a study conducted with an
appropriate control population. If the symptom
occurrence was higher when compared in this man-
ner, then a relationship might be hypothesized.
In our study, we selected control populations
that provided meaningful comparisons with a popu-
lation of patients with TMD. We included, at the
outset, the full range of patients being treated for
TMD. Inasmuch as tinnitus and vertigo symptom
occurrence increases with age, we chose two con-
trol groups of comparable ages. The first control
group (control group 1) was comprised of patients
seeking routine medical care. We postulated that
patients seeking medical care may be more focused
on chronic somatic symptoms,37 like the TMD
group. The second control group (control group 2)
was comprised of patients seeking routine dental
care. This represents a similar group of patients not
experiencing chronic symptoms. The working hy-
pothesis was that there is no association of tinnitus
and vertigo and TMD when compared with appro-
priate controls. The study thus tests the null hy-
pothesis.
MATERIALS AND METHODS
There were 1032 patients studied; of these, 338 were
being treated for temporomandibular disorders; 326 in
control group 1 were seeking routine medical care, and
365 in control group 2 were seeking routine dental care.
The TMD group was from private practices of clinicians
specializing in this problem. The control group 1 was
from private medical offices or the University of Califor-
nia at Davis Student Health Center. No specialty oto-
Iaryngologic practices were included. Control group 2
was comprised of patients presenting for dental hygiene
153
154 Parker and Chole American Journal of Orthodontics' and Dentofacial Orthopedics
February 1995

Table h Age distribution of study tinnitus is a very common symptom in the control
groups (in percent) population (13.8% in control group 1 and 32.5% in
Age TMD group Control I Control H
control group 2). Nevertheless, 59.0% of the pa-
tients with TMD experienced tinnitus. When ques-
11-20 15.0 11.3 8.6 tioned about "severe" vertigo, 28.0% of the TMD
21-30 25.5 24.8 15.3 group responded affirmatively, compared with only
31-40 30.5 16.9 29.1
6.0% and 8.3% in the control groups. About half of
41-50 16.0 13.2 17.9
51-60 8.0 10.2 10.1 the subjects in each of the three groups had uni-
61-70 4.5 13.2 11.8 lateral tinnitus and half had bilateral tinnitus. An
71-80 0.5 8.3 5.8 even more striking difference was noted when pa-
81-90 0.0 2.0 1.4 tients were asked if the tinnitus interfered with
sleep-17.1% of the TMD group had this com-
plaint. Only 3.2% and 5.0% of the control groups
in private offices and the Sacramento City College School had tinnitus of this magnitude. This difference
of Dental Hygiene. was highly significant (P = <0.001) (Fig. 1 and
Self-administered questionnaires with 11 questions Table Ill).
were used to collect the data. Reliability of such ques- Vertigo: Dizziness and vertigo were significantly
tionnaires has been verified by Heloe,~ Kopp, 3~ and more commonly reported in the TMD group than
Rieder. 4~ The information included name, age, sex, and in the other two groups (Fig. 2 and Table II).
history of arthritis, diabetes, heart disease, high blood Significantly more patients in the TMD group
pressure, surgery within the last year, ear pain (unilateral (70%) reported dizziness than in the control
or bilateral), severity of tinnitus, tinnitus that interferes groups (30.1% and 44.0%) (P = <0.001). When
with sleep, dizziness, spinning vertigo, severity of dizzi-
patients were asked specifically about the symptom
ness, and temporomandibular joint noises (unilateral or
of spinning vertigo and severe spinning vertigo,
bilateral).
To analyze the data, we selected only those patients significantly more patients in the TMD group re-
in the TMD group who had both clicking in the joint and ported this symptom than in the control groups
pain the region of the ear (the joint). So only persons (P < 0.001) (Table III). The most striking differ-
with evidence of dysfunction or derangement of the ence was seen in patients reporting severe vertigo
structures within the joint itself were included as patients in the TMD Group (20.0%); the percentages were
with TMD. This yielded 200 subjects. In the control much lower in the control groups (3.5% and 7.3%).
groups, patients were excluded if they had both joint pain Otalgia: As anticipated from the selection crite-
and joint clicking. This yielded 302 subjects in group 1 ria, 100% of the TMD group had otalgia, which
and 347 in group 2. included pain in the ear and in the vicinity of the
Statistical analyses were run on two levels to examine
ear. The incidence of otalgia in the control groups
the factors associated with the TMD group: Likelihood
was less than 10%, a statistically significant differ-
ratio X2 tests to examine the marginal associations and a
more sophisticated method fitting several log-linear mod- ence (P < 0.001) (Table III).
els to the data to assess the partial associations, while Gender: Because 87% of our TMD group was
adjusting for the other predictive factors. A progressive female subjects, as compared with a lower percent-
Bonferroni adjustment was made for multiple compari- age in the control groups, we corrected for gender
sons when differences appeared significant.41 with another set of comparisons. A log-linear
model was used to adjust for gender differences
RESULTS between groups. Tinnitus measures and vertigo
This random selection, plus defining the symp- were still more significant in the TMD Group.
toms, produced a study group and two control
groups of roughly comparable age distribution DISCUSSION
(Table I). The principal outcome variables of this The null hypothesis was not supported; aural
study were tinnitus and vertigo. Since both symp- symptoms of tinnitus and vertigo are more fre-
toms vary in severity, and tinnitus varies in lateral- quently found in patients with TMD than in com-
ity, several comparisons were made in each group parable age-matched populations. For over half a
(Table II). century, a number of authors have attempted to
Tinnitus: The patients in the TMD group had explain the pathogenesis of tinnitus and vertigo by
significantly more than those in the control group 1 disorders in the temporomandibular joint region.
or 2 (P = <0.001). As can be seen in Table II, Several hypotheses have been proposed. Some of
American Journal of Orthodontics and Dentofacial Orthopedics Parker and Chole 155
Volume 107, No. 2

Tinnitus
Percent Inck .~nt Incidence
60
50 60
40 50
30 40
2( ~0
lc 0
)

Ti~
3roup
Sew
p2
~ upt~ o~ccp Control (iroup ]
Fig. 1. Incidence of tinnitus in temporomandibular (TMD) group compared with two control groups.

Table II. Symptom summary for all subject groups (percent incidence)

ac,or l 1 [
Gender (female) 87.0 62.5 58.9
Arthritis 15.0 15.0 18.5
Hypertension 2.0 4.0 19.9
Prior surgery 17.5 6.6 8.61
Vertigo
Any dizziness 70.0 30.1 44.0
Vertigo 40.7 11.0 18.5
Severe vertigo 20.0 3.5 7.3
Otaigia
Unilateral 50.0 5.2 9.3
Bilateral 50.0 4.3 5.0
Tinnitus 59.0 13.8 32.5
Unilateral 22.5 3.2 13.3
Bilateral 36.5 10.6 19.2
Severe tinnitus 28.0 6.0 8.3
Unilateral 13.0 2.0 4.0
Bilateral 15.0 4.0 4.3
Disrupts sleep 17.1 3.2 5.0

these are frequently repeated in the dental litera-
ture as though they were fact and not just hypothe-
ses. A review is therefore in order.
Eustachian Tube Hypothesis: Costen s noted the
association of aural symptoms and TMD and pro-
posed that malpositioning of the mandibular
condyle as a result of TMD could lead to eusta-
chian tube blockage and symptoms of aural pain,
tinnitus, and vertigo; however, to our knowledge,
TMD has never been shown to affect eustachian
tube function.
The Tensor Tympani Hypothesis: Myrhaug 6 rea-
soned that the muscles of mastication and the
tensor tympani are innervated by the trigeminal
nerve and that hyperactivity of these muscles would
cause symptoms, such as tinnitus. This line of
reasoning is illogical: to cause the high-pitched
tinnitus observed in these patients with TMD, the
muscle would be contracting at an unrealistically
high frequency and the tinnitus would be objective
(audible by an observer), which it is not. The fact
that aural symptoms may abate after successful
treatment of TMD in no way provides the tensor
tympani hypothesis.
The OtomandibuIar Ligament Hypothesis: Some
authors 42'43 have suggested that the aural symptoms
156 P a r k e r a n d Chole American Journal of Orthodontics and Dentofacial Orthopedics
February t995

Vertigo
Percent Inch ~ntincidence
70 70
60 60
50 50
4(
3q ~0
2 ;0
1 0
3

Any Diz: Group

tp2
>evcre v cz ugo t2ontrol ~Jroup i

Fig. 2. Incidence of vertigo in temporomandibular (TMD) group compared with two control groups.

Table IIh Associations between groups and predictive factors

TMD versus control I TMD versus control H

Factor X2 X2 l P=

Gender 48.8 < 0.001 40.1 < 0.001

Arthritis 1.1 0.299 0.0 0.996
Diabetes 4.4 0.037 0.1 0.821
Heart disease 3.2 0.075 1.8 0.182
Hypertension 7.2 0.007 0.0 0.986
Prior surgery 8.7 0.003 15.2 < 0.001
Tinnitus 34.9 < 0.001 125.5 < 0.001
Severe 34.1 < 0.001 50.0 < 0.001
Disrupts sleep 19.6 < 0.001 31.3 < 0.001
Dizziness 33.4 < 0.001 80.1 < 0.001
Vertigo 29.2 < 0.001 63.8 < 0.001
Severe 17.6 < 0.001 39.1 < 0.001

associated with TMD are a result of direct me-
chanical stimulation of the malleus through the
anterior mallear ligament. The presence of ligamen-
tous structures from the malleus to the structures of
the temporomandibular joint is cited as the explana-
tion for aural symptoms. The ligaments have been
named the diskomalIeolar ligament and the mallear
portion of the sphenomandibular ligament. The disko-
malleolar ligament is a developmental remnant of
Meckle's cartilage and has been demonstrated in the
h u m a n f e t u s . 44 Although these ligaments e x i s t 45'46
and could conceivably transmit mechanical energy
to the malleus, they cannot account for high fre-
quency subjective tinnitus and vertigo from local
perturbations of the position of the malleus.
Excessive Somatic Concern (ESC) Hypothesis:
Temporomandibular disorder, tinnitus47'4s and ver-
tigo49 are all disorders that have been found to be
associated with emotional disorders. One possible
explanation for the high incidence of tinnitus and
vertigo in patients with TMD is that underlying
emotional distress may exacerbate all three symp-
toms. Brown and Walker37 have defined a proposed
syndrome in which complaints are disproportionate
to the severity of physical findings, a syndrome that
they term ESC. Previous studies of tinnitus and
vertigo did not control for the possibility that it was
this syndrome that accounted for the increase in
complaints in the TMD group. We attempted to
control for the possible confounding effects of the
ESC syndrome by including a control group of
patients seeking medical care, with the assumption
that this group would have a more comparable
number of subjects with this syndrome. We as-
Amelqcan Journal of Orthodontics and Dentofacial Orthopedics
Volume 107, No. 2
s u m e d that patients with E S C would be m o r e
prevalent in a p o p u l a t i o n of persons frequenting a
physician's office than in the general population,
and that patients with E S C are m o r e likely to have
multiple somatic complaints (i.e., polysymptomatic
somatization37). Despite this comparison, tinnitus
and vertigo were significantly increased in patients
with T M D .
SUMMARY
T h e present study, using a p p r o p r i a t e control
groups, verifies the relationship b e t w e e n T M D and
tinnitus, otalgia, and vertigo. T h e cause of the
symptoms of tinnitus and vertigo in patients with
T M D is unknown. T h e otalgia m a y possibly be
explained by the proximity o f the t e m p o r o m a n d i b u -
lar joint and the structures of the ear. A l t h o u g h we
f o u n d tinnitus and vertigo significantly m o r e preva-
lent in the T M D population than in the control
populations studied, this does not prove a causal
relationship. Study of this association m a y help to
u n d e r s t a n d b o t h the otologic symptoms of tinnitus
and vertigo and those o f T M D .
H y p e r t e n s i o n was not f o u n d to be m o r e fre-
quent in the T M D group. This finding was in
a g r e e m e n t with that of Weiss, 5° who f o u n d no
relation of systolic or diastolic pressure with tinni-
tus in a sample of 6672 adults, and that of Chatel-
lier et al., 51 who f o u n d no correlation b e t w e e n
blood pressure levels and tinnitus in 1771 u n t r e a t e d
hypertensive patients.
CONCLUSIONS
1. Tinnitus is highly significantly associated
with T M D c o m p a r e d with either control
group in this study.
2. Vertigo is highly significantly associated with
T M D c o m p a r e d with either control group in
this study.
3. R e p o r t e d high blood pressure was not f o u n d
to be significantly associated with tinnitus in
this study.
NOTE: This article includes a recapitulation of
data published in the Archives of OtoIaryngology-
Head & Neck Surge~ Aug. 1992, Volume 188, pages
817-821. Copyright 1992, American Medical Associ-
ation.
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