Temporomandibular joint disorder

From Wikipedia, the free encyclopedia

Jump to: navigation, search
Temporomandibular joint disorder
Classification and external resources

Temporomandibular joint
ICD-9 524.60
DiseasesDB 12934
MedlinePlus 001227
eMedicine neuro/366 radio/679 emerg/569
MeSH C05.500.607.221.897.897

Temporomandibular joint disorder (TMJD or TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry, neurology and chiropractic — there are a variety of treatment approaches.

The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, and neoplasia.

Contents

[edit] Signs and symptoms

Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex. Often the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth.[1] Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.


[edit] Temporomandibular joints

This is arguably the most complex set of joints in the human body. Unlike typical finger or vertebral junctions, each TMJ actually has two joints, which allow it to both rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of it. Clicking is common, as are popping motions and deviations in the movements of the joint. It is considered a TMJ disorder when pain is involved.

In a healthy joint, the surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues. When receptors from one of these areas are triggered, the pain causes a reflex to limit the mandible's movement. Furthermore, inflammation of the joints can cause constant pain, even without movement of the jaw.

Due to the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain.[2] The pain may be referred in around half of all patients and experienced as otalgia (earache).[3][4] Conversely, TMD is an important possible cause of secondary otalgia.[5] Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus,[6] as well as atypical facial pain.[7] Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.[8]

The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc.[9] The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.[citation needed]

[edit] Teeth

Disorders of the teeth can contribute to TMJ dysfunction.[10] Impaired tooth mobility and tooth loss can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion. Maybe the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle.

[edit] Precipitating factors

There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:

Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways (laterally) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:

  1. Trauma
  2. Repetitive unconscious jaw movements called bruxing.
  3. Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
  4. Jaw thrusting (causing unusual speech and chewing habits).
  5. Excessive gum chewing or nail biting.
  6. Size of foods eaten.
  7. Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
  8. Myofascial pain dysfunction syndrome
  9. Lack of Overbite

[edit] Treatment

[edit] Restoration of the occlusal surfaces of the teeth

If the occlusal surfaces of the teeth or the supporting structures have been damaged due to dental neglect, periodontal diseases or trauma, the proper occlusion should be restored. **There is currently a lack of evidence to support this statement**

[edit] Pain relief

While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neuralgic in nature, which often does not respond well to these drugs.[11]

An alternative approach is for pain modification, for which off-label use of low-doses of Tricyclic antidepressant that have anti-muscarinic properties (e.g. Amitriptyline or the less sedative Nortriptyline) generally prove more effective.[12][13]

[edit] Long-term approach

It is suggested that before the attending dentist commences any plan or approach utilizing medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.

An approach to eliminating para-functional habits involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and results in jaw pain. Palpation of these muscles will cause a painful response.

Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A flat-plane full-coverage oral appliance, e.g. a non-repositioning stabilization splint, often is helpful to control bruxism and take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may then prove helpful. This method of treatment is often referred to as "splint therapy."

According to the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), TMJ treatments should be reversible whenever possible. That means that the treatment should not cause permanent changes to the jaw or teeth.[14][15] Examples of reversible treatments are:

  • Over-the-counter pain medications, used according to manufacturers’ instructions.
  • Prescription medications prescribed by a healthcare provider.
  • Gentle jaw stretching and relaxation exercises you can do at home. Your healthcare provider can recommend exercises for your particular condition, if appropriate.
  • Feldenkrais TMJ Program, uses a unique understanding of human neurology to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJ symptoms[16][17].
  • Stabilization splint (biteplate, nightguard) is the most widely used treatment for TMJ and jaw muscle problems; however, the actual effectiveness of these splints is unclear. If an oral splint is recommended, it should be used only for a short time and should not cause permanent changes in the bite. If a splint causes or increases pain, stop using it and tell your healthcare provider. Avoid using over-the-counter mouthguards for TMJ treatment. If a splint is not properly fitted, the teeth may shift and worsen the condition.
  • Mandibular Repositioning (MORA) Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night. According to an article on Quackwatch.org, MORA devices are considered the most widley used option although the scientific validity has not been proven.

What may be concluded is that there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:

  • Manual adjustment of the bite by grinding the teeth (occlusal adjustment). This, too, is not a widly accepted practice and should be avoided as it is irreversible.
  • Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
  • Reconstructive dentistry
  • Orthodontics
  • Arthrocentesis (joint irrigation)
  • Surgical repositoning of jaws to correct congenital jaw malformations such as prognathism and retrognathia
  • Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)

Attempts in the last decade to develop surgical treatments based on MRI and CAT scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other therapeutic modalities have changed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving oral surgery as a last resort. Certainly a focus on other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining oral-facial pain specialist, oral surgeon or health professional. One option for oral surgery, is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as arthrocentesis.[18] In some cases, this will reduce the inflammatory process.

[edit] Jaw dislocation

The jaw can dislocate if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge. Dislocation can occur following a series of events if the jaw locks wide open and is unable to close by using the jaws muscles (unassisted) and without excessive force; cupping the palm of one hand under the chin and the other hands palm placed on top of the head, then using the arms muscles to force the jaw shut. As an immediate result of the dislocation, chronic pain can be experienced on both sides of the jaw, combined with an extreme headache and inability to concentrate.

Depending on the severity of the jaw's dislocation, pain relief using paracetamol (available over the counter at your local pharmacy) can assist to alleviate the initial chronic pain, however the effects of long-term use of paracetamol can decline as the condition deteriorates with continued use of the jaw through the day i.e. talking, eating, smoking, drinking, etc.

If a persons jaw locks open, never attempt to force it closed as described above, as this action can result in a dislocated jaw followed by chronic TMJD related pain.

[edit] Symptoms of a dislocated jaw

The symptoms can be numerous depending on the severity of the dislocation injury and how long the person is inflicted with the injury.

The immediate symptom can be a loud crunch noise occurring right up against your ear drum, except the sound is produced on the inside of your head and not only seems like you've breaking bones, but feels like it too. This is instantly followed by excruciating pain, particularly upon the side where the made impact

Short-term symptoms can range from mild to chronic headaches, muscle tension or pain in the face, jaw, neck, shoulders, back, arms and often in the legs.

Long-term symptoms can result in sleep deprivation, tiredness/lathargy, frustration, bursts of anger or short fuse, difficulty performing everyday tasks, depression, social issues relating to difficulty talking, hearing sensitivity (particularly to high pitched sounds), tinnitus and pain when seated associated with posture while at a computer and reading books from general pressure on the jaw and facial muscles when tilting head down or up.

You may also notice a sharp bolt of pain shoot down your body when you turn your head suddenly, this may be associated to the side of the jaw which is dislocated.

[edit] Medical assistance for dislocated jaw

In the event of a jaw locking or even jaw dislocation seek medical assistance immediately. Avoid seeking medical assistance or pain relief from a chiropractor, particularly if the chiropractor is complacent with twisting your neck left/right in order to crack your neck, as this can aggravate your symptoms from the pressure placed on the jaw and neck muscles as the chiropractor performs the manoeuvre.

[edit] Relocating a dislocated jaw

One technique which has proved useful for jaw relocation is a technique that requires the individual to undertake a specific stretch in the morning, not long after awakening and whilst still laying in bed, as the body's jaw and face muscles will be more relaxed at this point. If you have any other injuries seek medical advice as to whether this technique may be of personal benefit or not.

This technique is best done while laying on your back, keeping your mouth closed gently, head held straight or parallel to your body looking up at the ceiling and without using any force or physical pressure upon the body. Also it's best if your head is lying on a pillow before you start.

Step one: Start by slowly and effortlessly raising your arms up parallel behind your head. As you straighten your arms, use your feet and legs to carefully slide your body down towards the bottom end of your bed, at least until you have enough room to stretch your arms perfectly straight behind you and your head is no longer resting on the pillow. To avoid straining your jaw while you do this technique, continue to keep your head parallel with you body until step two.

Step two: Once your head is no longer resting on the pillow, slowly and gently arch your head backwards, as far back as it can comfortably go, also start arching your shoulders and your back into the air (towards the ceiling), keep your bottom on the bed and bend your knees up towards the ceiling so that either your heels are touching the bed or even the soles of your feet.

The next few steps are the most crucial and really depend on the way your jaw is dislocated (i.e. on the left or right hand side), therefore you will need to pay extra attention as you will literally feel and sense excessive movement on that side of your jaw which is dislocated and this sensation could even be described as a numbness.

Step three: while in this position, start to stretch or flex all your muscles, then at the same time very slowly and carefully open your jaw while trying to yawn if you can, as yawning is the critical factor to help relocate the jaw. As you yawn let your mouth open (don't try to keep it closed) and while you yawn breath in very slowly. While your mouth is opening/yawning, you might start to sense numbness in one or both sides of your jaw, take notice of this. If it seems there is pressure build up in your ear drums, try to yawn as if your going to unblock them.

Step four: With your mouth open, start using the muscles in your jaw and face to try not to let your mouth open completely or all the way. This part is important. You may hear your ear drums popping as they unblock, stay aware of a similar sound, as this sound is your jaw relocating and you will know it has when the TMJD symptoms disappear when it occurs. It is at this point that you should feel your jaw relocate back into its normal position and as it relocates you should expect not to experience pain. Do not immediately or quickly close your jaw after it relocates, as it may lock again, instead carefully and slowly close your jaw, gently wriggling your jaw back and forward to assist closing the jaw if needed.

If this technique helped relocate your jaw, you may experience a numb sensation around your jaw and area around your ear, which has to do with the pressure being taken off the jaw and face muscles. Be sure to allow your jaw and face muscles to rest for at least two weeks without excessively straining it (i.e. chewing steak, long conversation etc), as your muscles need to recover from the dislocation.

There is no guarantee your jaw will be perfect again, that it won't dislocated again or even partially dislocate, however you can use this technique again if further dislocation occurs. If you experience pain at any point undertaking this technique, stop immediately, read the steps again and determine if you did anything different and before attempting the steps again seek professional medical advice.

Refer your medical practitioner/s treating your TMJD or dislocation to the National Center for Emergency Medical Informatics NCEMI webpage explaining how to physically relocate your jaw, as this may help determine whether the method describing manual relocation is suitable to your injury. Do not attempt to relocate your jaw without professional medical assistance.

[edit] See also

The entry for "syndrome, Costen" in Dorland's Medical Dictionary is an all-encompassing definition of this symptom complex.

[edit] References

  • Okeson, Jeffrey P. (2003). Management of temporomandibular disorders and occlusion (5th ed.). St. Louis: Mosby. ISBN 0-323-01477-1. 

[edit] Footnotes

  1. ^ Okeson (2003), page 191.
  2. ^ Okeson (2003), page 233.
  3. ^ Tuz HH, Onder EM, Kisnisci RS (2003). "Prevalence of otologic complaints in patients with temporomandibular disorder". Am J Orthod Dentofacial Orthop 123 (6): 620–3. doi:10.1016/S0889-5406(03)00153-7. PMID 12806339. 
  4. ^ Ramírez LM, Sandoval GP, Ballesteros LE (2005). "Temporomandibular disorders: referred cranio-cervico-facial clinic". Med Oral Patol Oral Cir Bucal 10 Suppl 1: E18–26. PMID 15800464. http://www.medicinaoral.com/medoralfree01/v10Suppl1i/medoralv10suppl1ip18.pdf. 
  5. ^ Peroz I (2001). "[Otalgia and tinnitus in patients with craniomandibular dysfunctions]" (in German). HNO 49 (9): 713–8. PMID 11593771. 
  6. ^ Sobhy OA, Koutb AR, Abdel-Baki FA, Ali TM, El Raffa IZ, Khater AH (2004). "Evaluation of aural manifestations in temporo-mandibular joint dysfunction". Clin Otolaryngol Allied Sci 29 (4): 382–5. doi:10.1111/j.1365-2273.2004.00842.x. PMID 15270827. 
  7. ^ Quail G (2005). "Atypical facial pain--a diagnostic challenge" (PDF). Aust Fam Physician 34 (8): 641–5. PMID 16113700. http://www.racgp.org.au/afp/downloads/pdf/august2005/August_theme_quail2.pdf. 
  8. ^ Okeson (2003), page 234.
  9. ^ Okeson (2003), page 204.
  10. ^ Okeson (2003), page 227.
  11. ^ Vickers ER, Cousins MJ (2000). "Neuropathic orofacial pain. Part 2-Diagnostic procedures, treatment guidelines and case reports". Aust Endod J 26 (2): 53–63. PMID 11359283. 
  12. ^ Marbach JJ (1996). "Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment". Rheum. Dis. Clin. North Am. 22 (3): 477–98. doi:10.1016/S0889-857X(05)70283-0. PMID 8844909. 
  13. ^ Dionne RA (1997). "Pharmacologic treatments for temporomandibular disorders". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83 (1): 134–42. doi:10.1016/S1079-2104(97)90104-9. PMID 9007937. 
  14. ^ Lipton JA, Ship JA, Larach-Robinson D (1993). "Estimated prevalence and distribution of reported orofacial pain in the United States". J Am Dent Assoc 124 (10): 115–21. PMID 8409001. 
  15. ^ National Institutes of Health Technology Assessment Conference Statement. (1996). Management of temporomandibular disorders. Washington, D.C.: Government Printing Office.
  16. ^ http://www.tmj-lessons.com/"See also"
  17. ^ http://www.feldenkrais.com/
  18. ^ "Temporomandibular Disorders". The Cleveland Clinic. http://www.clevelandclinic.org/health/health-info/docs/3100/3152.asp?index=10960&src=news. 

[edit] External links

v • d • e
Dentistry
Recognized Specialties
(in the United States)
Unrecognized Specialties
(in the United States)
Cosmetic Dentistry - Dental Implantology - Temporomandibular Joint Disorder - Geriatric dentistry
Other
Procedures
See also
v • d • e
Oral pathology: Stomatognathic disease (K06-K14, 526-529)
Vestibule of mouth
Oral cavity proper
Hard, soft,
and periapical tissues
Dentofacial anomalies
Gnathitis · jaw abnormality (Micrognathism, Prognathism, Retrognathism)
Temporomandibular joint disorder
Maxillomandibular anomalies
Salivary glands
General
mouth navs: anat/dev, noncongen/congen face/congen GI/neoplasia, symptoms, proc
Retrieved from "http://en.wikipedia.org/wiki/Temporomandibular_joint_disorder"