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Temporomandibular Joint Disease
Aka: Temporomandibular Joint Disease, Temporomandibular Joint Syndrome, Temporomandibular Joint Disorder, Temporomandibular Joint Dysfunction, TMJ Dysfunction, Arthralgia of Temporomandibular Joint
- See Also
- Temporomandibular Joint
- Definition
- Temporomandibular Joint inflammation
- Epidemiology
- Affects 10-15% of adults (but only 5% pursue evaluation and treatment)
- Peak Incidence: 20-40 years old
- Twice as common in women
- Risk Factors
- Comorbid pain syndromes (e.g. Fibromyalgia, chronic Headaches)
- Autoimmune disorders
- Sleep Apnea
- Major Depression
- Anxiety Disorder
- Causes
- Malocclusion
- Displacement of condylar head
- Bruxism
- Trauma
- Acute synovitis
- Arthritis (Osteoarthritis or Rheumatoid Arthritis)
- Symptoms
- Pain on opening and closing mouth or chewing
- Consider alternative diagnosis if pain is not affected by jaw opening and closing
- Pain is classically anterior to tragus
- Worse in the morning
- Pain Radiation
- Facial pain (96%)
- Ear Pain (82%)
- Headache (79%)
- Jaw pain (75%)
- Cheek pain
- Temple pain
- Eye Pain
- Neck Pain
- Shoulder Pain
- Cooper (2007) Cranio 25(2): 114-26 [PubMed]
- Restricted Jaw function
- Jaw movement feels 'Tight'
- Sudden 'catching' suggests mechanical dysfunction
- Noise or crepitation at TMJ
- Clicking or grating sound (common and not a marker of worsening or improvement)
- Exacerbated by chewing
- Signs
- Temporomandibular Joint exam technique
- Apply index finger on either side of face
- Position finger preauricular over pretragal area or inside external meatus
- Patient opens mouth widely and closes several times
- Observe for
- Clicking or popping noises or Sensation
- Click on opening and again on closing suggests disc displacement with reduction
- Crepitation suggests TMJ Osteoarthritis
- Limited range of opening (Normally 4-5cm)
- Disc displacement may interfere with condyle translation (Closed lock)
- Subluxation (locking on opening)
- Deviation of jaw during movement (>7 mm lateral movement)
- TMJ Joint Pain on palpation
- Suggests intra-articular disorder
- Temporalis Muscle, masseter Muscle or neck Muscle tenderness on palpation
- Suggests masticatory Muscle disorder or myofacial pain
- Diagnosis
- Consider Temporomandibular Joint injection (Auriculotemporal Nerve Block)
- Consider alternative diagnosis if it does not relieve pain
- Classification
- TMJ due to articular disorder (intra-articular causes)
- Congenital disorder or tumor of the Mandible or cranial bones
- Articular disc displacement (most common intra-articular condition)
- Condylar process Fracture
- Anklyosis, synovitis, capsulitis or Osteoarthritis of the Temporomandibular Joint
- Temporomandibular Joint disclocation
- TMJ due to masticatory Muscle disorders (extra-articular causes, 50% of cases)
- Myofascial Pain
- Myofibrotic contracture
- Myositis or Muscle spasm
- Imaging (consider)
- Jaw XRay (Transcranial and transmaxillary or panorex views)
- Jaw CT
- Arthroscopy
- Jaw MRI
- Preferred imaging for a comprehensive imaging evaluation of the jaw
- Indicated in cases refractory to conservative management or with suspected intraarticular cause
- Test Sensitivity: 78-95%
- Test Specificity: 66-80% (up to a 34% False Positive Rate)
- Lamot (2013) Oral Surg Oral Med Oral Pathol Oral Radiol 116(2): 258-63 [PubMed]
- Jaw Ultrasound
- Consider as an alternative to Jaw MRI
- Bas (2011) J Oral Maxillofac Surg 69(5): 1304-10 [PubMed]
- Differential Diagnosis
- See Orofacial Pain
- TMJ Arthritis
- Management: General Measures
- General measures are effective in 80% of cases
- No chewing gum or ice, pencils
- Avoid tooth grinding and tooth clenching
- Avoid excessive jaw opening (e.g. yawning or on tooth hygiene such as Tooth Brushing)
- Very soft diet
- Analgesics
- NSAIDs are effective for local synovitis or Myositis
- Avoid Opioids
- Avoid Tramadol (ineffective)
- Avoid Topical Analgesics (ineffective)
- Local massage
- Heating pad or local moist heat as needed
- Elevate head of bed to 30 degrees or more
- Consider Temporomandibular Joint Diagnostic Injection
- Management: Bruxism and Chronic Pain Management (masticatory Muscle or myofacial pain)
- Muscle relaxants (e.g. Flexeril)
- Neuropathic Pain Medications
- Tricyclic Antidepressants at bedtime (e.g. Amitriptyline, Nortriptyline)
- Gabapentin
- Cognitive Behavioral Therapy or biofeedback
- Aggarwal (2011) Cochrane Database Syst Rev (11):CD008456 [PubMed]
- Physical therapy (weak support)
- McNeely (2006) Phys Ther 86(5): 710-25 [PubMed]
- Acupuncture
- Protocols of 6-8 sessions of 15-30 min each
- Rosted (2001) Oral Dis 7(2): 109-115 [PubMed]
- Cho (2010) J Orofac Pain 24(2): 152-62 [PubMed]
- Transcutaneous electrical nerve stimulation (TENS unit)
- Anxiolytics or Antidepressants
- Risk of Bruxism with SSRIs (rare)
- SSRIs and SNRIs appear ineffective for Chronic Pain of TMJ Dysfunction
- Benzodiazepines have been used for short 2-4 week courses (but risk of dependence)
- Onabotulinumtoxin A (Botox)
- Variable evidence
- Soares (2014) Cochrane Database Syst Rev (7): CD007533 [PubMed]
- Management: Dental Occlusion and intra-articular disorders
- Referral to oral and maxillofacial surgery for refractory cases
- Orthodontic appliances
- Nonoccluding splint (simple splints)
- Prevent teeth clenching and Bruxism by opening the jaw
- Inexpensive, pre-fabricated splints are available at pharmacies
- Occlusal dental device or night guard (Occluding splints, stabilization splints)
- Custom made to assist teeth alignment
- Price runs several hundred dollars due to custom fit and adjustment by dentist
- Alleviates symptoms in over 70% of TMJ patients
- Surgery
- Indicated in less than 5% of TMJ patients
- Consider in cases of refractory intra-articular disorders (see above)
- Procedures include Arthrocentesis, Diskectomy, condyotomy, total joint replacement
- Course: Prognosis
- Spontaneous resolution of symptoms (without any intervention) in 40% of patients
- Improvement in one year: 50%
- Improvement completely in 3 years: 85%
- References
- Buescher (2007) Am Fam Physician 76(10): 1477-84 [PubMed]
- Dimitroulis (1998) BMJ 317: 190-4 [PubMed]
- Gauer (2015) Am Fam Physician 91(6): 378-86 [PubMed]
- Shankland (2004) Gen Dent 52: 349-55 [PubMed]
- Truelove (2006) J Am Dent Assoc 137:1099-107 [PubMed]