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Temporomandibular joint dysfunction

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Temporomandibular joint dysfunction
SpecialtyOral medicine Edit this on Wikidata

Temporomandibular joint disorder (TMJD or TMD), or TMJ syndrome, is an acute or chronic inflammation of the temporomandibular joint, which connects the lower jaw 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, physical therapy and psychology—there is a variety of quite different treatment approaches.

Signs and symptoms

Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex. Due to the different anatomic structures involved, it is easy to group the symptoms accordingly into three categories. The anatomic structures affected in TMD are the muscles, the temporomandibular joints, and the teeth.[1]

Muscles

Disorders of the muscles of the temporomandibular joint are the most common complaints by TMD patients.[2] The two major observations concerning the muscles are pain and dysfunction. In TMD, the muscle pain is described as a "deep pain" and does not seem to be simply from overuse and fatigue.[2] Instead, it is believed that this pain is a result by mechanisms from the central nervous system.

In these cases, muscle pain can sometimes be associated with trigger points in muscle tissue.[3] The trigger points are attributed to deep, constant pain and to causing the pain to be referred to other parts of the body. For example, the trapezius muscle refers pain more commonly to the ear, temple, and angle of the jaw, while the occipital belly of the occipitofrontalis muscle refers pain to behind the eye.[4] Trigger points residing in the shoulder muscles can also cause muscle disorders of the temporomandibular joint.[5]

Trigger points are also involved with associated migraines in TMD, even though migraines themselves are not fully an aspect of TMD.[6] When pain of the temporomandibular joint precedes migraines, then treatment of the TMD may reduce the number of migraines, but TMD treatment is not a "cure" for migraines.[6] Other kinds of headaches can be an expression of the pain produced by trigger points.[7]

The dysfunction involved is usually a restriction on mandibular movement upon opening of the mouth. In some cases, it is possible to continue opening the mouth if done slowly, but the pain may stay present or intensify.[8] Additionally, the dysfunction of the muscles may cause the teeth to occlude with each other incorrectly. This condition is called an acute malocclusion and is the result of TMD, not the cause.[8]

Temporomandibular joints

Disorders of the temporomandibular joints are usually the most noted observation upon examination of TMD patient because most signs are readily detected by the clinician, not necessarily the patient.[9] The two major observations concerning the joints are pain and dysfunction. In a healthy joint, the surfaces in contact with one another do not have any receptors to transmit the feeling of pain. The pain therefore must originate from one of the surrounding soft tissues: the discal ligaments, the capsular ligaments, and the retrodiscal tissue.[9] 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 close proximity of the ear to the temporomandibular joint, TMJ pain can be expressed as ear pain.[7] The pain may be referred in around half of all patients and experienced as otalgia (earache).[10] [11] Conversely, TMD is an important possible cause of secondary otalgia [12] Treatment of TMD may then significantly reduce symptoms of otalgia and tinitus,[13] as well as atypical facial pain[14]. Despite some of these findings, there are some researchers who question whether TMD therapy can reduce symptoms in the ear, and currently a debate is ongoing to settle the controversy.[15]

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 is usually described as a "click" or a "pop" when a single sound is heard. When there are multiple, rough sounds, it is described as "crepitation" or "crepitus".

Teeth

Disorders of the teeth can also be present in TMD patients.[16] Tooth mobility can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. 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. The heavy forces on the teeth have been associated with the presence of mandibular tori in TMD patients.[17] Pulpitis, inflammation of the dental pulp, is another symptom that may result. It is usually caused by heavy forces on the teeth and can cause pain. Lastly, tooth wear is the most common sign associated with a dysfunction of the teeth, but it is not strongly associated with TMD symptoms.[18] Tooth wear can be a result of bruxism or by interfering with the movement of the mandible during function, referred to as the "functional envelope of motion." Depending on the cause, the treatment for tooth wear differs.

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 wayward habits or a malalignment of the jaw or dentition. This may be due to:

  1. Modification of the occlusal surfaces of the teeth though dentistry or accidental trauma.
  2. Speech habits resulting in jaw thrusting.
  3. Excessive gum chewing or nail biting.
  4. Excessive jaw movements associated with exercise.
  5. Repetitive unconscious jaw movements associated with bruxing.
  6. Size of foods eaten.

Treatment

Restoration of the occlusal surfaces of the teeth

If the occlusal surfaces of the teeth have been damaged though dentistry or accidental trauma, the proper occlusion must be restored through modification of the occlusal surfaces of the teeth.

Pain relief

While conventional analgesic pain killers such as paracetamol 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.

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. Because of their primary therapeutic functions are for psychiatric disorders their use should be monitored by a physician.

Long term approach

It is suggested that before the attending doctor 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 puts strain of the muscles of mastication (chewing) and resultant 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 stabilisation splint, often is helpful to control bruxism and take stress off the temporomandibular joint, albeit the fact that that 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.

Mandibular Repositioning Devices can be worn for a short term to help alleviate symptoms related to painful clicking when opening the mouth wide but 24 hour wear for long term may lead to changes in the position of the teeth which 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. Full mouth reconstruction, or building up of teeth to achieve the proper bite relation is not supported by strong evidence based studies.

Surgical

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, splinting, or more recently neuromuscular dentistry 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[19]. In some cases, this will reduce the swelling of the joint, and allow for fluid movement when the jaw opens and closes.

See also

  • WebMD Includes some basic treatments
  • Migraine Headache Pain has some information regarding TMJ/TMD problems
  • . GPnotebook https://www.gpnotebook.co.uk/simplepage.cfm?ID=-194314226. {{cite web}}: Missing or empty |title= (help)
  • Template:FPnotebook
  • MedlinePlus Overview temporomandibularjointdysfunction
  • 08-116a. at Merck Manual of Diagnosis and Therapy Home Edition
  • TMJ, (in pdf format) by the American Association of Oral and Maxillofacial Surgeons

Footnotes

  1. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 191.
  2. ^ a b Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 192.
  3. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 198.
  4. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 199.
  5. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 201.
  6. ^ a b Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 232.
  7. ^ a b Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 233.
  8. ^ a b Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 193.
  9. ^ a b c Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 204.
  10. ^ Tuz H, Onder E, Kisnisci R (2003). "Prevalence of otologic complaints in patients with temporomandibular disorder". Am J Orthod Dentofacial Orthop. 123 (6): 620–3. PMID 12806339.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Ramírez L, Sandoval G, Ballesteros L (2005). "Temporomandibular disorders: referred cranio-cervico-facial clinic" (PDF - English & Spanish). Med Oral Patol Oral Cir Bucal. 10 Suppl 1: E18-26. PMID 15800464. {{cite journal}}: Text "month Apr 1" ignored (help)CS1 maint: multiple names: authors list (link)
  12. ^ Peroz I (2001). "[Otalgia and tinnitus in patients with craniomandibular dysfunctions]". HNO. 49 (9): 713–8. PMID 11593771.
  13. ^ Sobhy O, Koutb A, Abdel-Baki F, Ali T, El Raffa I, Khater A (2004). "Evaluation of aural manifestations in temporo-mandibular joint dysfunction". Clin Otolaryngol Allied Sci. 29 (4): 382–5. PMID 15270827.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Quail G (2005). "Atypical facial pain--a diagnostic challenge" (PDF). Aust Fam Physician. 34 (8): 641–5. PMID 16113700.
  15. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 234.
  16. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 227.
  17. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 229.
  18. ^ Okeson, Jeffrey P. "Management of Temporomandibular Disorders and Occlusion". 5th edition. Mosby, Inc. 2003. ISBN 0-323-01477-1. Page 230.
  19. ^ "Temporomandibular Disorders", the Cleveland Clinic.
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