Temporomandibular joint pain dysfunction syndrome

 

 

This is the most common problem in and around the temporomandibular joint (TMJ) or the jaw joint. Jaw problems affect a person’s ability to speak, eat, chew, swallow and even breathe.

 

Epidemiology

Predominantly affects people aged between 20—40 years old. Equal frequency between genders, but five times as many females seek treatment. Affects around 40% of the population at some time in their life.

Etiology

Idiopathic:  It is like to be associated with one of the following: occlusal abnormalities, lack of posterior support, parafunctional clenching habits, nocturnal bruxism, anxiety and depression.  (50-70% of patients have experiences stressful life events in the 6 months before onset.) Occasionally the patient may relate the onset of pain to an acute incident of local trauma while eating or yawning.

 

Symptoms

• Unilateral or bilateral constant dull pain within the TMJ and/ or surrounding muscles around the ear.
• Pain on chewing, yawning or talking
• Some people may not have pain but still have problems using their jaws.
• If bilateral, one side usually worse
• Trismus, limited jaw movements
• Occasionally the TMJ may lock open or closed
• Sounds—clicking, crunching or grating (crepitus) are often described
• Headaches, facial pain and neck related aches
• Cyclic pain which usually resolves, but may recur
• A bite that is uncomfortable or feels “off”.
• Swelling on the side of the face, neck, shoulder, and back pain.
• Ringing in the ear, decreasing hearing, dizziness, and vision problems.

 

 

Signs

• Joint clicking—generated by displacement of the articular disc from head of condyle and then ‘popping’ back into correct position
• Pain may be elicited on palpation of the TMJ and masticatory muscles. The muscles may be hypertrophic due to parafunction
• Mandibular movement may be limited and deviation may occur on the opening or closing cycle
• Parafunction habits in up to 50% of cases
• Bruxism can be suggested by scalloping of the lateral borders of the tongue, ridging of the buccal mucosa, tooth wear, restoration wear, fracture, dentine exposure and sensitivity

Investigations

 

Organic causes of pain or limited movement should be ruled out by investigation.  Radiography is not recommended for diagnosis unless there is a history of trauma, significant limitation of movement, sensory or motor alteration, or a possibility of organic joint or other disease.  Trigeminal neuralgia can be occasionally triggered by movement of the jaw and should be suspected in older patients, particularly where pain is severe and paroxysmal.

Management

• Many people with TMJ problems get better without treatment. Often the problem goes away on its own in several weeks to months.
• Most cases are self-limiting; therefore treatment should be conservative and reversible i.e., without causing any permanent changes to jaw or teeth.
• Patient information is an important aspect - Reassure and Explain
• Habit management – Rest, avoidance of trauma and gentle jaw stretching and relaxation exercises.
• Occlusal appliances (biteplate, nightguard)
• Analgesia (NSAID’s), heat and massage, TENS
• Muscle relaxants (Clonazepam or Baclofen) can give relief
• Psychological Rx: hypnosis, behavior modification, group therapy

 

 

Occasionally anxiolytic medications (diazepam 5mg 1 hour before sleep, then 2mg twice daily, for up to 10 days maximum) can be useful. Antidepressant medication (tricyclics) where indicated. Occlusal adjustment of the natural teeth by selective grinding is irreversible and not recommended.

Orthodontics is an option for repositioning of teeth.

 

Surgery may be required for the very small number of non-responders, especially those with obvious intra-articular pathology (osteoarthritis)

E.g. condylotomy, capsular rearrangement, silicone/teflon implants, auriculotemporal nerve section