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Temporomandibular dysfunction or TMD refers to a range of disorders causing pain in the pre-auricular area and muscles of mastication. It is the most common non-dental cause of orofacial pain and often goes hand in hand with other chronic pain disorders such as headaches and fibromyalgia. This article will discuss the aetiology and clinical signs of TMD and then outline its management.


Anatomy

913_Tempomandibular_Joint

Figure 1 showing the temporomandibular joint. The meniscus is located between the head of the mandibular condyle and the glenoid fossa of the temporal bone and can contribute to clicking and locking of the joint.


Causes

Multifactorial pathophysiology with no conclusive theory on the exact cause of the condition but thought to relate to:

  • Stress
  • Low mood
  • Bruxism (Tooth grinding)
  • Co-morbidities such as chronic pain (Fibromyalgia, Chronic Fatigue Syndrome, Back pain, Headache)
  • Trauma to the teeth/face causing malocclusion (an abnormal bite)

Clinical features

Pain in the pre-auricular area (can radiate to jaw/temporal region)

Clicking (due to “sticking” of the meniscus/disc)

Locking (where the disc becomes trapped preventing the jaw from closing)

Trismus (reduced mouth opening)


Examination

Inspection

This should include inspection of the mouth and teeth to rule out any dental pathology and an examination of the patient’s occlusion (bite).

 

Palpation

Palpation of the TMJs bilaterally and the muscles of mastication should help define where the pain is located. Place your fingertips just anterior to the tragus to feel for clicking, locking and local tenderness. In addition, patients often complain of pain along the insertions of the masseter and temporalis muscles and so it is worth palpating there too.

Ask the patient to open and close their mouth whilst palpating the joint to detect clicking. Any deviation or locking of the jaw can be observed at this point (i.e. where the mouth doesn’t open fully in a straight line.)


Management

The aim of treatment is to eliminate pain and aid a return to normal jaw function. The vast majority of cases can be managed conservatively with only a small minority requiring invasive surgical management.

 

Conservative management

Explanation and reassurance – probably the most important aspect of management as explaining the benign nature of the condition often helps significantly

Identification of problem habits such as nail biting and chewing gum

Jaw exercises (advice sheets are available online and in OMFS units)

 

Pharmacotherapy

  • Regular NSAID treatment – reduction in pain and inflammation around the TMJ.
  • A short course of Amitriptyline (a tricyclic antidepressant) can be used in more severe cases of pain.

 

Splint therapy – often helps reduce bruxism and jaw clenching at night. Requires referral to a Dentist or Oral Surgery unit.

Physiotherapy – improves joint function through jaw stretch and muscle relaxation.

Acupuncture – Often done by the physiotherapist alongside physiotherapy.

 

Surgical management

Only to be considered for patients refractory to the above measures.

It includes procedures such as:

  • Arthrocentesis
  • Arthroscopy
  • Arthroplasty
  • TMJ replacement surgery (rare)

Always consider other important differential diagnoses such as giant cell arteritis and oropharyngeal tumours and ask for help if unsure.


References

  1. Dwonkin SF. The OPPERA study: Act One. J pain 2011; 12: T1-T3
  2. Durham J, Newton-John TR, Zakrzewska JM. Temporomandibular Disorders. BMJ2015;350:h4154
  3. Ghurye S, McMillan R. Pain-Related Temporomandibular Disorder – Current Perspectives and Evidence-Based Management. Dental Update 2015; 42 (6): 533-546
  4. TMJ image: Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

 

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