Temporomandibular Joint Disease

1. See Also
   1. Temporomandibular Joint
2. Definition
   1. Temporomandibular Joint inflammation
3. Etiologies
   1. Malocclusion
   2. Displacement of condylar head
   3. Bruxism
   4. Trauma
   5. Acute synovitis
   6. Arthritis (Osteoarthritis or Rheumatoid Arthritis)
4. Symptoms
   1. Pain on opening and closing mouth
      1. Pain is classically anterior to tragus
      2. Worse in the morning
      3. Radiation
         1. Ear Pain
         2. Cheek pain
         3. Temple pain
         4. Neck Pain
         5. Shoulder Pain
   2. Restricted Jaw function
      1. Jaw movement feels 'Tight'
      2. Sudden 'catching' suggests mechanical dysfunction
   3. Noise or crepitation at TMJ
      1. Clicking or grating sound (common and not a marker of worsening or improvement)
      2. Exacerbated by chewing
5. Signs
   1. Temporomandibular Joint exam technique
      1. Apply index finger on either side of face
         1. Position finger preauricular over pretragal area or inside external meatus
      2. Patient opens mouth widely and closes several times
   2. Observe for:
      1. Clicking noises
      2. Limited range of opening (Normally 4-5cm)
      3. Subluxation (locking on opening)
      4. Deviation of jaw during movement
      5. Pain to palpation of joint
6. Diagnosis
   1. Consider Temporomandibular Joint Diagnostic Injection
7. Classification
   1. TMJ due to articular disorder
      1. Congenital disorder or tumor of the Mandible or cranial bones
      2. Articular disc displacement
      3. Condylar process Fracture
      4. Anklyosis, synovitis, capsulitis or Osteoarthritis of the Temporomandibular Joint
      5. Temporomandibular Joint disclocation
   2. TMJ due to masticatory muscle disorders
      1. Myofascial pain
      2. Myofibrotic contracture
      3. Myositis or muscle spasm
8. Imaging (consider)
   1. XRay
   2. Arthroscopy
   3. MRI
9. Differential Diagnosis
   1. See Orofacial Pain
10. Management: General Measures (Effective in 80% of cases)
    1. No chewing gum or ice
    2. Very soft diet
    3. Analgesics
       1. NSAIDs are effective for local synovitis or Myositis
    4. Local massage
    5. Heating pad or local moist heat as needed
    6. Elevate head of bed to 30 degrees or more
11. Management: Bruxism and Chronic Pain Management
    1. Muscle relaxants (e.g. Flexeril)
    2. Tricyclic Antidepressants at bedtime (e.g. Amitriptyline)
    3. Cognitive behavioral therapy
    4. Transcutaneous electrical nerve stimulation (TENS unit)
    5. Anxiolytics or Antidepressants
       1. Risk of bruxism with SSRIs (rare)
12. Management: Dental Occlusion
    1. Orthodontic appliances
       1. Nonoccluding splint (simple splints)
          1. Prevent teeth clenching and bruxism by opening the jaw
          2. Inexpensive, pre-fabricated splints are available at pharmacies
       2. Occlusal dental device (Occluding splints, stabilization splints)
          1. Custom made to assist teeth alignment
          2. Price runs several hundred dollars due to custom fit and adjustment by dentist
          3. Alleviates symptoms in over 70% of TMJ patients
    2. Surgery
       1. Indicated in less than 5% of TMJ patients
13. Course: Prognosis
    1. Improvement in one year: 50%
    2. Improvement completely in 3 years: 85%
14. References
    1. Buescher (2007) Am Fam Physician 76(10): 1477-84
    2. Dimitroulis (1998) BMJ 317: 190-4
    3. Shankland (2004) Gen Dent 52: 349-55
    4. Truelove (2006) J Am Dent Assoc 137:1099-107