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Temporomandibular Joint Disorders (TMJD)

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Head, Jaw, Face, and Neck Pain

Moshir Mehta

 

 

Contents

• Introduction

• What are the Temporomandibular Joints?

• Signs and Symptoms of Temporomandibular Disorders (TMJD)

• Headaches

• Face Pain

• Eye Pain

• Ear symptoms

• Neck Pain

• Bite Changes

• Problems with Sleep and Stress

• Types of TMJ Disorders

• Joint Related (Internal Derangements of the TM Joint)

• Muscle related pains (Myofascial Pain)

• Neck related pains

• Orofacial Pains

• How can you tell you have a TMJ disorder?

• What will my physician or dentist do to diagnose my condition?

• Treatments of Temporomandibular Disorders

• Treatments provided by the dentist or the physician

• Pain Management

• Stress management

• Physical medicine

• Dental splint therapy

• Treatment of disc displacement

• Surgical treatments

• Summary

• For more information on TMJD, please visit:

• Image Citations

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Introduction 

The term Temporomandibular Joint Disorders is an umbrella term covering a number of acute and chronic problems related to areas of the head, jaw, face and neck [1]. TMJD affects more than 10 million Americans and is more common in women then men [2]. Most people affected by this syndrome have multiple signs and symptoms of pain in the TMJ jaw joints, face, and muscles of the head and neck [3].  Some may also suffer from chronic headaches and facial pains related to neurological and psychological issues. As a group these symptoms are termed TM Disorders syndrome [4].

In the medical community, TMJD is often called “The Great Imposter.”  This nickname stems from the difficulty that most dentists have in diagnosing TMJD because of the wide range of symptoms associated with it [5]. While most people narrow it down to pain related directly to the temporomandibular joint, the reality is that TMJD covers much more than this narrow definition would allow.  In this knol, I will cover the basics of pain related to the TM joint.  However, I will also be going into the less known symptoms, including psychological and neurological issues that can be helped through TMJD treatment [6].  

What are the Temporomandibular Joints?

The temporomandibular joints (TMJ) connect the lower jaw (mandible) to the temple bone (temple) on the sides of the skull.  (Figure 1) The left and right joints both allow the jaw to move up and down as well as side to side during chewing, yawning, and speaking. This is unique in the human body, as no other structure uses two joints to move one bone: the mandible.

Each temporomandibular joint has a rounded ball like end of the lower jaw (condyle) which can move within a space of the skull (temporal) bone called a fossa. Separating these two bones during function is a pad of fibrous cartilage called an articular disc. Each articular disc acts as a cushion and is attached to the condyle of the lower jaw, moving with it to prevent the bones from rubbing together during function [7]. 

[pic]

Signs and Symptoms of Temporomandibular Disorders (TMJD)

The following symptoms of TMJD can also be related to serious underlying medical conditions. Always have your physician evaluate you prior to seeking treatment for TMJD.

Headaches

[pic]The International Headache Society classifies headaches related to TMJD as tension headaches characterized by dull, deep, and constant aches. Often there is a description of a band-like tightening or pain on the sides of the head, or along the front or the back of the head. Headaches may occur more often in the morning or may be of varying levels throughout the day.  

Morning headaches may be related to night-time tooth clenching or grinding and have been known to coexist with common sleep disorders. Increasing pain during the day may be related to the effect of gravity on neck and head posture. Muscular headaches are the most common form of headaches in humans and can be quite severe, leading to their common misdiagnosis as migraines. See your physician urgently if your headaches are new and occur quickly, especially if they are accompanied by weakness, confusion or any loss of consciousness [8].

Face Pain

Pain in the sides of the lower jaw, or pain felt as “sinus” pain in the cheek or eye areas, may also have a musculoskeletal (muscles and joints together) origin. Missing back teeth may result in a reduction of the height of the bite. When combined with daytime clenching due to stress, this can create muscle trigger points, muscle fatigue, and pain. This is particularly noticeable after meals and reported as “a heavy and tired feeling” in the jaw muscles [9].

Eye Pain 

Frequently, pain in the eyes accompanies headaches caused by TMJD. Initial symptoms start as a tightness in the skull’s base (occipital) region that spreads to the side of the head, ultimately affecting the eye as pressure usually referred to as ”feeling like a squeezing of the eyeball.” This is frequently seen in people with a history of head and neck trauma affecting upper neck (cervical) vertebrae or muscles that compress nerve roots (nerve root impingements).  Neck muscles tighten and can trap nerves from the neck, triggering eye and head pain. This is often diagnosed as Occipital Neuralgia. In addition to nerve related medications, treatment of the cervical area with physical medicine techniques – along with changes in head posture and jaw position – frequently help this condition [10].

[pic]Ear symptoms

Pain, stuffiness, and ringing in the ears (tinnitus) may be part of TMJD syndrome. The same nerves that supply a group of chewing muscles (medial pterygoids) also supply the middle ear muscles (tensor tympani and tensor palati). The shape, position and size of the upper and lower teeth directly affect jaw posture, and have been known to cause ear pain, stuffiness and pressure changes in adults as well as play a role in middle ear infections in children.

Tinnitus has many causes. In TMJD patients, ringing and other ear sounds may be caused by neck muscle tension or improper jaw position.  A combination of physical medicine and dental mouth guard therapy have been effective in cases where there has been a history of trauma or improper growth and development of the jaw during childhood [11].

Neck Pain

Almost 75 % of TMJD patients also complain of stiffness and pain in the neck. Poor habitual head posture and jaw muscle tension chronically affect the neck area, creating pain, stiffness and tenderness in the muscles of the head and neck.

It is well documented that nerves to the head and neck are intertwined and work together to maintain proper head, neck and jaw posture. The normal acts of chewing, swallowing and speech rely on all the muscles of the neck. In addition, jaw posture and head posture interact to maintain the airway space required for breathing while awake and asleep. This is the reason why dentists are also involved in treating sleep disorders such as sleep apnea.  If you jaw is out of position, it can also lead to snoring at night, which can act as an early warning that you should see your dentist.

Studies on the relationships of the bite and neck have shown that loss of vertical height or missing back teeth resulting in a deep bite can lead to chronic stiffness, pain and reduction of the range of motion of the neck. It is therefore important to also have a dental evaluation of the bite if an individual has chronic neck symptoms [12].

Bite Changes

Frequently, joint and muscle problems can affect the bite and cause a change in the way the upper and lower teeth come together. This sometimes leads to tooth pain and can result in unnecessary treatment of the teeth by the dentist.

The bite (dental occlusion) of an individual is known to be a significant factor in TMJD. The way the lower teeth fit within the confines of the upper teeth in a full closed bite is important to the comfort of the muscles and the temporomandibular joints. Think of the upper teeth being the lid that fits properly over the opening of the jar. When you bring your teeth together, the bite should close without a shifting of your jaw. A sliding of the lower teeth against the upper should alert you to a possible tooth-related TMJ type problem. Improper jaw position is a very common finding in patients with TMJD and aggravates the pain in the jaw.  Temporarily using a dental bite guard helps to stabilize the jaw joints, and prevents ongoing muscle imbalance without permanent changes to the teeth [13].

Problems with Sleep and Stress

Moderate to severe TMJD pain frequently has a side affect of disturbed sleep and increased anxiety. Pain ongoing for three months or more can lead to psychological depression. In some individuals increased stress from daily living and preexisting psychological issues can make the pain and disability of TMJD worse, creating an ongoing cycle where pain creates more pain [14]. 

Types of TMJ Disorders

It is important to note that while the term TMJ Disorders are named for the temporomandibular joints, only 20-25% of patients have a pure joint-related problem. The rest suffer from a combination of muscular, joint and nerve pains that fit into the following broad categories [15].

• Joint related (Internal Derangements of the TM Joint)

• Muscle related (Myofascial Pain and Trigger points)

• Neck related (Craniocervical disorders)

• Orofacial Pains 

• Nerve related Orofacial Pains (Neurogenic pain or neuralgias)

• Stress related Orofacial Pains (psychogenic and psychosocial pain disorders)

Joint Related (Internal Derangements of the TM Joint)

[pic]In the temporomandibular joints, sounds such as clicking, popping or grating when opening the jaw are actually more common than pain. Hearing these noises is an easy, early indicator of suffering from TMJD. The noises usually occur on one side of the jaw.  If accompanied by pain, it usually feels like the pain is radiating from the jaw to the ear.

Joint sounds are symptoms of a forward disc displacement, where the disc or cartilage in the joint slips out of position. If the disc is slipping in and out of position during chewing, the main symptom you will experience is clicking noises upon jaw movement. If left untreated, this may progress to a locked jaw in a small number of patients.  In this situation, opening is limited and painful and the pad of cartilage cannot come back into its normal position [16].

While disc displacements as described above are the most common joint problems, other types do exist and need to be evaluated by a professional [17].

• Inflammatory Disorders: Trauma, irritation, or infections can affect the joint and its surrounding parts. If the joint is inflamed, you will feel extreme tenderness when pressing on the TM joint, which will be accompanied by pain on opening. Joint inflammation may also be a result of general arthritis. This is similar to joint changes in other joints of the body and may be related to connective tissue diseases affecting the same population of patients.

• Osteoarthritis (non-inflammatory): Primary osteoarthritis is a degenerative condition of the joints related to overload. This is frequently seen in patients with a long history of worn down or missing and unreplaced teeth. This process is usually slow, and generally does not have pain associated with it in the early stages. There may be grating sounds in the joint during jaw movement. Radiographs or computed tomography (CT) scans can verify if there have been any changes from wearing in the joint. 

• Fracture: Trauma to the chin, mandible or any part of the face may result in bony fractures of the condylar neck, condylar head, body of the mandible and the maxilla and temporal fossa. These will generally result in pain and a reduction in jaw opening, which if left untreated can lead to a frozen joint (fibrous or bony ankylosis). Surgery may be necessary to unfreeze the joint, as well as post surgical mobilization techniques. Your surgeon will give you more information on this.

Muscle related pains (Myofascial Pain)

Muscular pain and dysfunction are the most common symptoms of a patient with temporomandibular disorders. The muscles of the masticatory (chewing) system are affected in the same way as other skeletal muscles of the body [18].

The most common muscular disorders are the following:

Muscle pain due to injury

Muscle pain is often caused by an injury to the muscle tissue.  Muscle injury can happen if there is direct trauma to the muscle or a sudden exertion of forces which can tear muscle fibres. When a muscle is injured, the best way for it to heal is to allow it to rest. In the jaw muscles, however, it is difficult to eliminate movement due to the need for speech, swallowing, and chewing. In addition, if there is constant clenching and tooth grinding the healing process takes longer. In acute or chronic injuries to the temporomandibular joints, the muscles that support and move the joints can begin to spasm. This is called a protective muscle splinting and helps to prevent further injury to the joint. Focusing the treatment to the joint first results in a relaxation of the muscle, whereas focusing treatment on the spasms can actually cause further damage.

Muscle Pain related to tooth grinding

(For more information on tooth grinding, please see the Bruxism knol)

In most patients, tooth grinding (bruxism) occurs in a mild, occasional form, and does not require treatment. However, constant grinding can lead to long-term TMJD problems.  Moderate or severe bruxism and clenching can damage oral structures by causing wear on the teeth and gums, bone breakdown alongside inflammation, and muscular dysfunction.

The treatment for tooth clenching and grinding works hand-in-hand with treatments for stress and sleep problems. These include biofeedback, stress management, medication, and psychological counseling. The best way to protect against developing a bruxism problem is by wearing a dental guard at night on your upper teeth.

Muscle pain related to posture

Long periods of sitting without moving as in watching television or working at a desk or at a computer can also lead to the neck muscles tightening and developing tender and sore points in the back of the neck. These are called trigger points. Trigger points are tender areas that when pressed produce pain in other areas of the jaw and face. Studies have shown that forward head posture leads to shortening and greater tension of the back and neck muscles.  The stability and function of the neck relies on the posture of the head and shoulders; in turn, the fit of the upper and lower teeth depends on the stability and function of the neck.  Hence, if you suffer from bad posture, it can have a dangerous affect on your body, leading to trigger points and ongoing issues with TMJD.

Neck related pains

[pic]Regular stretching and flexing of the muscles will help in preventing the most common muscle symptoms.  Acute or long-standing trauma from a fall or an automobile accident can cause an irritation of tissues in the back of the neck. The pain may then extend from the back of the head to the eye, the side of the head, the face, and the jaw. The average neck injury is usually not a direct trauma to the neck, but rather a low-grade impact to the body, which causes a sudden twisting or jerking of the neck.  The classic example of this is whiplash from a car accident.  

The symptoms may range from headaches, nausea, visual disturbances, neck weakness, pain, and stiffness accompanied by noises upon rotation, flexion, and extension of the head.  Treatment can be simple home care techniques such as ice, stretching, over the counter pain medications, exercise and posture change. In more severe or chronic pain you may need to see your doctor, who may recommend a specialist to do a full evaluation as to the reasons of your ongoing neck pain.

Orofacial Pains 

These following pains are not usually considered related to the TM joint. However, they are part and parcel of the overall TMJD syndrome and do affect a large percentage of pain patients. They are included in this knol for completeness [19].

Neuropathic or nerve related pains

Pain from nerves in the head, face and neck is one of the most difficult and confusing of TMJD symptoms to diagnose and treat. Collectively called Neuropathic Pain Disorders, they affect a range of nerves, including the central nervous system of the brain, spinal cord, and peripheral nerves of the body, and the nerves of the face and the teeth.

Peripheral nerves of the body conduct sensations of touch, temperature, burning and pain. These sensations are transmitted by secondary nerves of the spinal cord to the brain, where the injury is perceived as pain. Chronic injury or pain often causes a spreading of pain that continues even after the injured nerve has healed. This chronic pain now continues almost as if it has a mind of its own.  There are a number of neuropathic pains; however, we will only touch on the ones affecting the head, face, and teeth.

Trigeminal Neuralgia (T.N.):  T.N. has a classic pattern of a sudden sharp, shooting pain that lasts only a few seconds and is similar to an electric shock. It can be triggered by a light touch, a breeze, or sudden changes in temperature. Patients are afraid to touch the face, shave or sometimes even comb their hair as facial touch or movement can trigger it.  As its name signifies, this is a nerve disorder of the trigeminal nerve and is more common after the age of 50.

[pic]

The trigeminal (three-part) nerve has three branches providing sensation to the side of the face: one branch goes to the eye area, the second to the upper teeth and cheekbones, and the third to the lower teeth and the jaw (See image at left). The neuralgia can follow any one of these branches and is believed by some to be related to compression of the nerve by either a vein or an artery in the brain. The truth is that there is no general consensus on what causes T.N.  If you are suffering from similar symptoms, you should be evaluated by a neurologist or specialist in treatment of T.N [20].

Atypical Odontalgia

Nerve pain triggered by dental injury to the root canal or the gums can also progress into a chronic, persistent pain. The pain is resistant to dental treatments, and even after a root canal or removal of the tooth the patient complains of a severe, constant pain felt in the site of the missing tooth. The pain then moves to an adjacent tooth, and the pain treatment cycle begins again, often leading to the unnecessary and harmful loss of the second tooth. Chronic persistent tooth pain in the absence of physical evidence is called Atypical Odontalgia [21].

Treatment

Neuropathic pains do not respond to dental procedures and these should be avoided until a thorough history and examination is done of the muscles and nerve functions of the head, neck, and face. Diagnostic imaging like CT scans, MRIs or even plain X-rays can help decide what form of treatment would be effective in treating the pain. The common initial treatment of neuralgias is the use of anti seizure medications like carbamazepine (Tegretol) or gabapentin (Neurontin). Your doctor will decide on the best medication and dose for your situation.

Psychological and stress related orofacial pains 

It is well known that acute or chronic stress can trigger pain in the head and neck by increasing muscle tension in the body. In temporomandibular disorders, this tension can trigger sleep disturbances such as bruxism or daytime, stress-related clenching, resulting in jaw pain.

Frequently however, pain can trigger a secondary stress response.  Most people perceive pain as being temporary.  If you get a cut or bruise, you expect the pain to go away after a certain amount of time. If the problem continues, the individual gets concerned and seeks medical care with the expectation that it will be treated and get better. If that happens, the anxiety level decreases. If, however, the initial treatment is not successful, and follow up treatments do not work, the anxiety now turns to a feeling of hopelessness. The American Psychological Association states that pain that lasts for more than a three-month duration can bring on depression. Depression increases the pain felt by lowering the person’s defenses to fight against it, as well as making it harder to treat the original pain syndrome.  In essence, if you are in pain and it doesn’t go away, you can create more pain through your stress level.

Treatment is usually targeted at the initial pain, as well as aimed at reducing anxiety and depression. Anti-anxiety medications such as clonazepam or antidepressants such as fluoxetine (Prozac) and, more recently, duloxetine (Cymbalta) have the ability to reduce pain and boost your mood [22].

How can you tell you have a TMJ disorder?

According to the Academies of Orofacial Pain and Craniofacial Pain, if you have more than three of the following on a regular basis you should see your dentist:

• Your jaw getting “ stuck”, “locked” or “going out”

• Difficulty and/or pain opening your mouth, such as when yawning

• Difficulty and/or pain when chewing, talking, or using your jaws

• Tiredness or heaviness of the jaw after eating

• Pain in or about the ears, temples, or cheeks

• Soreness of jaw muscles

• Clenching or grinding of your teeth

• An unusual or uncomfortable bite

• Frequent headaches

• Chronic stiff neck or pain in the neck muscles

• Burning, sharp shooting pains in your teeth or face that is short lasting

• Clicking, popping or grating sounds in your TM joint 

• Ear pain related to chewing motion

What will my physician or dentist do to diagnose my condition?

As you have seen in the discussion so far, the term “Great Impostor” is an accurate description of TMJD, and there are no standard tests covering all the different types of TM disorders.  Your doctor or dentist will take a full medical and dental history, so it is a good idea to make a list of problems you have experienced by dates or years that you can refer to at the appointment or to give to your professional to place in your record.

You should include-

• History of any physical trauma such as falls, sports injuries, physical assaults and automobile accidents.

• Your known medical conditions, regardless whether you feel they may be connected to the present problem.

• All medications you have taken or are taking for all of your medical conditions. Remember to list vitamins and herbal remedies you may be taking as they tend to interact with other drugs the doctor may prescribe.

• Medical or surgical procedures you might have had in the past, especially around the head, face and neck regions.

• Past and present dental procedures, such as braces, crowns, surgeries, or implants.

• List all past treatment providers and what you were or are seeing them for.

• List all of your chief concerns by order of importance to you. Being clear and concise will allow your doctor to review it with you.

Your treatment provider will do an examination that usually follows a clinical examination of your head, face, teeth, jaws, and neck. This may vary based on your symptoms. The examination may include a hands-on evaluation with the doctor or dentist feeling your head and jaw muscles and the temporomandibular joints.  It should also include an evaluation of your teeth and bite, as well as an intra-oral cancer check.

If you have problems related to stress or other parts of the body, the doctor or dentist may refer you to a specialist for further assessment.  If you have not had a full medical physical within the last six months to one year with laboratory tests, you may be asked to do so.

Diagnostic imaging for the temporomandibular joints may be required. Usually the dentist will take a panoramic radiography, which is a scan of your teeth and joints as a screen. Following this, a CT scan or MRI may be ordered to look at the joints in more detail.

Some dentists use specific instrumentation such as: surface Electromyography (EMG), which measures muscle function; a stethoscope or joint sonography for joint sounds; and axiography, which uses a computer to record the way the lower jaw and upper jaw move together. The dentist also may take moulds (impressions) of your teeth and use a dental articulator to duplicate how your upper and lower teeth come together in your mouth.

Treatments of Temporomandibular Disorders

It is strongly recommended that initial treatments be kept conservative and reversible so as not to cause permanent changes or damage to the structures or tissues of the jaw and teeth.

Since the most common pains of the jaw joints and muscles are temporary and do not last, there are some home care techniques you can use during the course of other treatments that may be prescribed.

Home or self care techniques

For TM joint pain (pain over the jaw joint in front of the ear):

• Apply ice over the jaw joint. Do not use ice directly on the joint so as not to freeze the skin. Wrap the ice in a cloth and then apply for a few minutes at a time until the area feels cold and the pain is reduced.

• Eat soft foods that do not require a wide opening of the mouth or hard chewing. However, you do want to maintain some jaw motion by gently opening and closing the mouth, as long as it does not cause pain.

• Avoid chewing gum and support your lower jaw with your hand to prevent yawning too widely. Avoid excessive stretching of the mouth until you can see the dentist.

• Use over-the-counter pain medication like acetaminophen (Tylenol) or anti-inflammatory pain-reducers like ibuprofen (Advil), aspirin, and naproxen (Aleve) as recommended. Do not use these if you have a history of ulcers, and only use them for a short period of time until you see the dentist.

For Muscle pain (pain over the side of the head and face)

• Use ice on the sore spot if there is pain, warmth and swelling due to an injury.

• Use wet heat for muscle tightness or pain.

• You can gently stretch the jaw muscles by using your fingers. 

• If you wake up in the morning with pain in your jaw from grinding, a temporary night guard from a drug store can be tried until you get to see the dentist. Usually these are “boil and bite” types that keep the upper and lower teeth apart and allow the muscles to relax.

• Topical pain reducers such as those commonly used for muscle pain or cramps can also be applied to the muscle skin surface and gently massaged into the skin.

• Relaxation and yoga techniques that allow you to relax and release stress can also be helpful to reduce pain in muscles.

Treatments provided by the dentist or the physician

Pain Management

Frequently the doctor will prescribe pain medication, sleep medication, muscle relaxants, or antidepressants. Generally, narcotic medications are not recommended for muscle and joint pains of TMJD, but they may be used for short-term severe pain if carefully supervised by the doctor [23].

Stress management

Increased stress can cause muscle tension and pain. This is why your dentist or doctor may inquire about your daily stress level. Your truthful and accurate answers to such questions can only benefit you by allowing the doctor to help design a multi-pronged treatment incorporating psychological help [24].

Physical medicine

Frequently your doctor will recommend physical therapy, chiropractic adjustments, or other physical treatments. These include the use of instruments such as ultrasound, pulsed radiofrequency energy, and transcutaneous electrical nerve stimulation (TENS). Craniosacral technique, massage, and myofascial releases help for muscle tension while joint mobilization and range of motion exercises help with joints. Complementary medical techniques like acupuncture, acupressure, herbal nutrients, topical analgesic creams, and some alternative therapies like yoga and energy releases have recently been found to be helpful in chronic pain patients [25].   

Dental splint therapy 

(For more information on splint therapy, please see the Mouth Guards knol)

[pic]The dentist will frequently recommend a dental guard or splint made out of clear acrylic to be worn between the upper and lower teeth. Usually a lower guard is recommended for the day, as it is easier to wear, is not visual and allows for better speech. An upper guard is worn at night as it allows for the lower jaw to rest against a stable upper arch. It also allows the lower jaw to be positioned to prevent nighttime tooth grinding. These splints are temporary and serve the purpose of relaxing the jaw muscles, allowing the TM joints to stabilize and, in the case of disc displacements, allowing a recapture of the slipped disc.

The dentist may decide that your bite height and tooth positions need to be addressed in order to stabilize the jaw position after the pain and dysfunction have healed, but caution is advised as an incorrect bite may not have been the major cause of the problem. Very often increased stress, tension of the muscles, and problems with the joints can throw the bite off, and once all of these factors are reduced the bite tends to settle down and does not require changing [26]. 

Treatment of disc displacement

Your dentist will first evaluate the disc position by checking the jaw joints and the muscles of the jaw. In addition, the dentist will assess your joint pain during opening and closing, and then measure your mouth’s ability to open; depending on what the dentist finds, these assessments may result in diagnostic magnetic resonance imaging (MRI) of the joint in question. Based on the findings, the following options may be suggested:  

• If the clicking sound has no pain associated with it, the dentist may just decide to watch the symptoms over time. A hard plastic dental mouth guard worn at night reduces the possibility of the problem progressing, as most locking of the jaw tends to happen during sleep, especially if you clench or grind at night.

• If there is an injury to the joint with pain but without swelling or reduction in jaw motion, the dentist may recommend over the counter anti-inflammatory medications such as aspirin, ibuprofen (Advil), or naproxen (Aleve) and the application of ice to the joint. A diet of soft foods for a couple of days, followed by a slow return to normal function and a follow up visit, would also be appropriate.

• If there is swelling and reduction in mouth opening the dentist may recommend a specialist trained in TMJ and orofacial pain for further treatment.  The specialist will evaluate if there is a fracture or a disc displacement that is not allowing the jaw to move. Swelling can also come from an infection of the TM joint, which may need antibiotic therapy and follow up care. A mouth guard might be prescribed to separate the upper and lower teeth to help reduce joint pain and relax the muscles of the jaw.

• In cases where the disc has slipped forward, it may twist on itself and prevent the condyle of the joint from moving. This causes pain and reduction in mouth opening. Usually the opening is reduced down to one finger’s width inserted to the first digit between the upper and lower front teeth. Treatment can include an anesthetic injection of the joint space along with manipulation of the joint to see if the disc can be “recaptured” or brought back into position. If this happens, the jaw opening will return to normal and the pain will be relieved. The dentist will also make a mouth guard that will need to be worn 24/7 immediately after the procedure for the first week. A soft diet for the time the guard is in place will help in the overall reduction in symptoms. The dentist will need to follow up during the healing phase. After the first week, the guard can be taken out during meals but should remain in the mouth the rest of the time. Your dentist will decide when you can safely stop wearing a guard or begin wearing it only at night.

• Immediate assistance may be required if the joint swells up to the point where it starts to affect swallowing. Antibiotics, prescribed pain medication, and emergency care for the swelling require close follow up by a trained specialist.

Surgical treatments

Joint surgery is the treatment of last resort and needs to be evaluated carefully. Your doctor needs to explain the short and long term outcomes of joint surgery, as there is no agreement in the field for the use of TMJ surgeries. In fact, fewer joint surgeries are being recommended today for patients with TM joint internal derangements than in the past. If surgery is considered, then minor procedures like arthrosynthesis, (a flushing out of the joint space) and arthroscopy (the scoping the joint to visualize and treat) are now used in conjunction with the non-invasive techniques discussed above. 

In cases of severe joint degeneration, the doctor may recommend artificial jaw implants. These have a poor outcome and may even cause more degenerative changes, requiring surgery. Multiple surgeries are to be avoided at all costs as the chance of a pain free, successful outcome is slim.

Summary

The most successful treatments of temporomandibular joint disorders should concentrate on stabilization of the bite with dental guards or splints, physical therapy, or orthopedic corrections for cervical problems and stress management to reduce body and muscle tension pain.

For more information on TMJD, please visit:

Tufts University Craniofacial Pain, Headache and Sleep Center - Dr. Mehta's office homepage

National Institute of Health: Clinical Trials in TMJ 

The American Equilibration Society

American Academy of Craniofacial Pain

American Academy of Orofacial Pain

American Academy of Orofacial Pain: Common Neuropathic Orofacial Pain Disorders and Their Treatment 

American Headache Society Committee for Headache Education- ACHE is a national non-profit patient/physician partnership providing support for sufferers of chronic headache while working to educate the public.

The International Classification Of Headache Disorders [PDF file will open]

Image Citations

Image 1- Image copyright SmartDraw Suite Edition.  Used under license. Altered by Dr. Noshir Mehta.

Image 2- Image copyright SmartDraw Suite Edition.  Used under license. Altered by Dr. Emad Abdallah.

Image 3- Image copyright SmartDraw Suite Edition.  Used under license. Altered by Dr. Noshir Mehta.

Image 4- Image by Dr. Noshir Mehta.

Image 5- Image copyright SmartDraw Suite Edition.  Used under license. Altered by Dr. Noshir Mehta.

Image 6- Image copyright SmartDraw Suite Edition.  Used under license. Altered by Dr. Noshir Mehta

Image 7- Image by Dr. Noshir Mehta.

References

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2. TMJ Disorders : National Institute of Dental and Craniofacial Research : NIH Publication No. 06-3487 : Revised June 2006

3. GELB H: Present-day concepts in diagnosis and treatment of craniomandibular disorders. N Y State Dent J 1985;51:266-271.

4. Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

5. Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

6. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV: Oro-facial pain in the community: prevalence and associated impact. Community Dent Oral Epidemiol 2002;30:52-60.

7. Pullinger AG, Bibb CA, Ding X, Baldioceda F: Relationship of articular soft tissue contour and shape to the underlying eminence and slope profile in young adult temporomandibular joints. Oral Surg Oral Med Oral Pathol 1993;76:647-654.

8. The International Classification of Headache Disorders: 2nd edition: Cephalalgia 2004;24 Suppl 1:9-160. SEE ALSO: Ciancaglini R, Radaelli G. The relationship between headache and symptoms of temporomandibular disorder in the general population. J Dent 2001;29(2):93-8.

9. Macfarlane TV, Blinkhorn AS, Davies RM, Kincey J, Worthington HV: Oro-facial pain in the community: prevalence and associated impact. Community Dent Oral Epidemiol 2002;30:52-60. SEE ALSO: Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

10. de las Penas CF, Cuadrado ML, Gerwin RD, Pareja JA: Referred pain from the trochlear region in tension-type headache: a myofascial trigger point from the superior oblique muscle. Headache 2005;45:731-737. SEE ALSO: GELB H: Present-day concepts in diagnosis and treatment of craniomandibular disorders. N Y State Dent J 1985;51:266-271. SEE ALSO: Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

11. Kuttila S, Kuttila M, Le BY, Alanen P, Suonpaa J: Characteristics of subjects with secondary otalgia. J Orofac Pain 2004;18:226-234. SEE ALSO: Gelb H, Bernstein I. Clinical evaluation of two hundred patients with temporomandibular joint syndrome. J Prosthet Dent 1983;49(2):234-43. SEE ALSO: Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

12. Chakfa AM, Mehta NR, Forgione AG, Al-Badawi EA, Lobo SL, Zawawi KH: The effect of stepwise increases in vertical dimension of occlusion on isometric strength of cervical flexors and deltoid muscles in nonsymptomatic females. Cranio 2002;20:264-273. SEE ALSO: GELB H: Present-day concepts in diagnosis and treatment of craniomandibular disorders. N Y State Dent J 1985;51:266-271. SEE ALSO: Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

13. Mehta.N, Abdallah.E, Lobo-Lobo. S, Ceneviz. C , Correa Vasquez. : Three –Dimensional Assessment of Dental Occlusion ( Occlusal Fencing ). A Clinical Technique: Dentistry India, 12 -17. vol. 1 No. 1, Fall 2007

14. Merskey H, Bogduk N: Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. ed Second Edition, IASP Press, 1994.

15. Okeson J: Orofacial pain: Guidelines for assessment ,diagnosis and management. The American Academy of Orofacial Pain. Quintessence, 1996. SEE ALSO: Gelb H: Clinical management of head neck and TMJ pain and dysfunction. Second Edition Saunders publishing. Philadelphia. 1985. SEE ALSO: Mehta N R, Forgione AG, Rosenbaum RS, Holmberg R: "TMJ" triad of dysfunctions: a biologic basis of diagnosis and treatment. J Mass Dent Soc 1984;33:173.

16. lfving L, Helkimo M, Magnusson T: Prevalence of different temporomandibular joint sounds, with emphasis on disc-displacement, in patients with temporomandibular disorders and controls. Swed Dent J 2002;26:9-19.

17. Okeson J: Orofacial pain: Guidelines for assessment ,diagnosis and management. The American Academy of Orofacial Pain. Quintessence, 1996

18. Mehta. N : Muscular disorders: In Kaplan A and Assael .L . Temporomandibular Disorder: diagnosis and treatment. Chapter 8. Saunders Publishing. Philadelphia. SEE ALSO: Travell J. and Simons, D. Myofascial Dysfunction: trigger point manual. Williams and Wilkins Baltimore 1983

19. Okeson J: Orofacial pain: Guidelines for assessment ,diagnosis and management. The American Academy of Orofacial Pain. Quintessence, 1996

20. Scrivani SJ, Keith DA, Mathews ES, Kaban LB: Percutaneous stereotactic differential radiofrequency thermal rhizotomy for the treatment of trigeminal neuralgia. J Oral Maxillofac Surg 1999;57:104-111.

21. Frediani F: Typical and atypical facial pain. Ital J Neurol Sci 1999;20:S46-S48.

22. Rugh J. Behavioral Therapy. In Textbook of Occlusion . Mohl N, Zarb G. Carlsson, G, Rugh .J. (eds) Quintessence Publishing Co. Lombard IL,

23. Dworkin SF: Benign chronic orofacial pain. Clinical criteria and therapeutic approaches. Postgrad Med 1983;74:239-8

24. Rugh J. Behavioral Therapy. In Textbook of Occlusion . Mohl N, Zarb G. Carlsson, G, Rugh .J. (eds) Quintessence Publishing Co. Lombard IL

25. Travell J. and Simons, D. Myofascial Dysfunction: trigger point manual. Williams and Wilkins Baltimore 1983

26. Simmons HC, III, Gibbs SJ: Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI. Cranio 2005;23:89-99.1988. SEE ALSO: Al-Ani Z, Gray RJ, Davies SJ, Sloan P, Glenny AM: Stabilization splint therapy for the treatment of temporomandibular myofascial pain: a systematic review. J Dent Educ 2005;69:1242-1250.

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Noshir Mehta

Verified

Professor and Chairman of General Dentistry and Director of the Craniofacial Pain Center

Tufts Dental School, Boston MA

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