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Temporomandibular Joint Disease

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Temporomandibular Joint Disease, Temporomandibular Joint Syndrome, Temporomandibular Joint Disorder, Temporomandibular Joint Dysfunction, TMJ Dysfunction, Arthralgia of Temporomandibular Joint

  • Definition
  • Epidemiology
  1. Affects 10-15% of adults (but only 5% pursue evaluation and treatment)
  2. Peak Incidence: 20-40 years old
  3. Twice as common in women
  • Risk Factors
  1. Comorbid pain syndromes (e.g. Fibromyalgia, chronic Headaches)
  2. Autoimmune disorders
  3. Sleep Apnea
  4. Major Depression
  5. Anxiety Disorder
  • Causes
  1. Malocclusion
  2. Displacement of condylar head
  3. Bruxism
  4. Trauma
  5. Acute synovitis
  6. Arthritis (Osteoarthritis or Rheumatoid Arthritis)
  • Symptoms
  1. Pain on opening and closing mouth or chewing
    1. Consider alternative diagnosis if pain is not affected by jaw opening and closing
    2. Pain is classically anterior to tragus
    3. Worse in the morning
  2. Pain Radiation
    1. Facial pain (96%)
    2. Ear Pain (82%)
    3. Headache (79%)
    4. Jaw pain (75%)
    5. Cheek pain
    6. Temple pain
    7. Eye Pain
    8. Neck Pain
    9. Shoulder Pain
    10. Cooper (2007) Cranio 25(2): 114-26 [PubMed]
  3. Restricted Jaw function
    1. Jaw movement feels 'Tight'
    2. Sudden 'catching' suggests mechanical dysfunction
  4. Noise or crepitation at TMJ
    1. Clicking or grating sound (common and not a marker of worsening or improvement)
    2. Exacerbated by chewing
  • 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 or popping noises or sensation
      1. Click on opening and again on closing suggests disc displacement with reduction
      2. Crepitation suggests TMJ Osteoarthritis
    2. Limited range of opening (Normally 4-5cm)
      1. Disc displacement may interfere with condyle translation (Closed lock)
    3. Subluxation (locking on opening)
    4. Deviation of jaw during movement (>7 mm lateral movement)
    5. TMJ Joint Pain on palpation
      1. Suggests intra-articular disorder
    6. Temporalis muscle, masseter muscle or neck muscle tenderness on palpation
      1. Suggests masticatory muscle disorder or myofacial pain
  • Diagnosis
  1. Consider Temporomandibular Joint injection (Auriculotemporal Nerve Block)
    1. Consider alternative diagnosis if it does not relieve pain
  • Classification
  1. TMJ due to articular disorder (intra-articular causes)
    1. Congenital disorder or tumor of the Mandible or cranial bones
    2. Articular disc displacement (most common intra-articular condition)
    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 (extra-articular causes, 50% of cases)
    1. Myofascial pain
    2. Myofibrotic contracture
    3. Myositis or muscle spasm
  • Imaging (consider)
  1. Jaw XRay (Transcranial and transmaxillary or panorex views)
  2. Jaw CT
  3. Arthroscopy
  4. Jaw MRI
    1. Preferred imaging for a comprehensive imaging evaluation of the jaw
    2. Indicated in cases refractory to conservative management or with suspected intraarticular cause
    3. Test Sensitivity: 78-95%
    4. Test Specificity: 66-80% (up to a 34% False Positive Rate)
    5. Lamot (2013) Oral Surg Oral Med Oral Pathol Oral Radiol 116(2): 258-63 [PubMed]
  5. Jaw Ultrasound
    1. Consider as an alternative to Jaw MRI
    2. Bas (2011) J Oral Maxillofac Surg 69(5): 1304-10 [PubMed]
  • Differential Diagnosis
  • Management
  • General Measures
  1. General measures are effective in 80% of cases
  2. No chewing gum or ice, pencils
  3. Avoid tooth grinding and tooth clenching
  4. Avoid excessive jaw opening (e.g. yawning or on tooth hygiene such as Tooth Brushing)
  5. Very soft diet
  6. Analgesics
    1. NSAIDs are effective for local synovitis or Myositis
    2. Avoid Opioids
    3. Avoid Tramadol (ineffective)
    4. Avoid Topical Analgesics (ineffective)
  7. Local massage
  8. Heating pad or local moist heat as needed
  9. Elevate head of bed to 30 degrees or more
  10. Consider Temporomandibular Joint Diagnostic Injection
  1. Muscle relaxants (e.g. Flexeril)
  2. Neuropathic pain medications
    1. Tricyclic Antidepressants at bedtime (e.g. Amitriptyline, Nortriptyline)
    2. Gabapentin
  3. Cognitive Behavioral Therapy or biofeedback
    1. Aggarwal (2011) Cochrane Database Syst Rev (11):CD008456 [PubMed]
  4. Physical therapy (weak support)
    1. McNeely (2006) Phys Ther 86(5): 710-25 [PubMed]
  5. Acupuncture
    1. Protocols of 6-8 sessions of 15-30 min each
    2. Rosted (2001) Oral Dis 7(2): 109-115 [PubMed]
    3. Cho (2010) J Orofac Pain 24(2): 152-62 [PubMed]
  6. Transcutaneous electrical nerve stimulation (TENS unit)
  7. Anxiolytics or Antidepressants
    1. Risk of Bruxism with SSRIs (rare)
    2. SSRIs and SNRIs appear ineffective for Chronic Pain of TMJ Dysfunction
    3. Benzodiazepines have been used for short 2-4 week courses (but risk of dependence)
  8. Onabotulinumtoxin A (Botox)
    1. Variable evidence
    2. Soares (2014) Cochrane Database Syst Rev (7): CD007533 [PubMed]
  • Management
  • Dental Occlusion and intra-articular disorders
  1. Referral to oral and maxillofacial surgery for refractory cases
  2. 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 or night guard (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
  3. Surgery
    1. Indicated in less than 5% of TMJ patients
    2. Consider in cases of refractory intra-articular disorders (see above)
    3. Procedures include arthrocentesis, diskectomy, condyotomy, total joint replacement
  • Course
  • Prognosis
  1. Spontaneous resolution of symptoms (without any intervention) in 40% of patients
  2. Improvement in one year: 50%
  3. Improvement completely in 3 years: 85%