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Diagnosis and Treatment of Temporomandibular Disorders ROBERT L Diagnosis and Treatment of Temporomandibular Disorders ROBERT L. GAUER, MD, and MICHAEL J. SEMIDEY, DMD, Womack Army Medical Center, Fort Bragg, North Carolina Temporomandibular disorders (TMD) are a heterogeneous group of musculoskeletal and neuromuscular conditions involving the temporomandibular joint complex, and surrounding musculature and osseous components. TMD affects up to 15% of adults, with a peak incidence at 20 to 40 years of age. TMD is classified asintra-articular or extra- articular. Common symptoms include jaw pain or dysfunction, earache, headache, and facial pain. The etiology of TMD is multifactorial and includes biologic, environmental, social, emotional, and cognitive triggers. Diagnosis is most often based on history and physical examination. Diagnostic imaging may be beneficial when malocclusion or intra-articular abnormalities are suspected. Most patients improve with a combination of noninvasive therapies, including patient education, self-care, cognitive behavior therapy, pharmacotherapy, physical therapy, and occlusal devices. Nonsteroidal anti-inflammatory drugs and muscle relaxants are recommended initially, and benzodiazepines or antidepressants may be added for chronic cases. Referral to an oral and maxillofacial surgeon is indicated for refrac- tory cases. (Am Fam Physician. 2015;91(6):378-386. Copyright © 2015 American Academy of Family Physicians.) More online he temporomandibular joint (TMJ) emotional, and cognitive triggers. Factors at http://www. is formed by the mandibular con- consistently associated with TMD include aafp.org/afp. dyle inserting into the mandibular other pain conditions (e.g., chronic head- CME This clinical content fossa of the temporal bone. Muscles aches), fibromyalgia, autoimmune disor- conforms to AAFP criteria Tof mastication are primarily responsible for ders, sleep apnea, and psychiatric illness.1,3 for continuing medical education (CME). See movement of this joint (Figure 1). Temporo- A prospective cohort study with more CME Quiz Questions on mandibular disorders (TMD) are character- than 6,000 participants showed a twofold page 356. ized by craniofacial pain involving the joint, increase in TMD in persons with depression Author disclosure: No rel- masticatory muscles, or muscle innervations (rate ratio = 2.1; 95% confidence interval, evant financial affiliations. of the head and neck.1 TMD is a major cause 1.5 to 3; P < .001) and a 1.8-fold increase ▲ Patient information: of nondental pain in the orofacial region. in myofascial pain in persons with anxiety A handout on this topic, Population-based studies show that TMD (rate ratio = 1.8; 95% confidence interval, written by the authors of affects 10% to 15% of adults, but only 5% 1.2 to 2.6; P < .001).5 Smoking is associated this article, is available seek treatment.2,3 The incidence of TMD with an increased risk of TMD in females at http://www.aafp.org/ 6 afp/2015/0315/p378-s1. peaks from 20 to 40 years of age; it is twice younger than 30 years. html. as common in women than in men and car- ries a significant financial burden from loss Classification of work.4 Symptoms can range from mild dis- TMD is categorized as intra-articular comfort to debilitating pain, including limi- (within the joint) or extra-articular (involv- tations of jaw function. ing the surrounding musculature).7 Muscu- The spectrum for TMD is reflected in its loskeletal conditions are the most common classification (eTable A). The most common cause of TMD, accounting for at least 50% syndromes are myofascial pain disorder, of cases.8,9 Articular disk displacement disk derangement disorders, osteoarthritis, involving the condyle–disk relationship is and autoimmune disorders. The discussion the most common intra-articular cause of of acute dislocations, trauma, and neoplasia TMD.10 is beyond the scope of this article. In 2013, the International Research Diag- nostic Criteria for Temporomandibular Etiology Dysfunction Consortium Network pub- The etiology of TMD is multifactorial and lished an updated classification structure includes biologic, environmental, social, for TMD (eTable A). 378Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2015 American AcademyVolume of Family 91, Physicians. Number For 6 the◆ March private, 15,noncom 2015- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Nonsteroidal anti-inflammatory drugs should be recommended for initial pharmacotherapy of TMD. C 37, 44, 47, 51 The addition of a muscle relaxant is recommended if there is clinical evidence of muscle spasm. Cognitive behavior therapy and biofeedback improve short- and long-term pain management for B 10, 36 patients with TMD. Occlusal adjustments of the teeth (i.e., grinding the enamel) should not be recommended for the B 61 management or prevention of TMD. Referral to an oral and maxillofacial surgeon should be recommended for patients in whom conservative C 10, 14, 62 therapy is ineffective and in those with functional jaw limitations or unexplained persistent pain. TMD = temporomandibular disorders. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort. Lateral pterygoid muscle Temporalis muscle 2 2 Medial pterygoid muscle 3 Temporal bone fossa Articular disk 2 Auditory 1 canal Mandibular condyle Temporomandibular joint Close-up of temporomandibular joint Masseter muscle ILLUSTRATION ENID BY HATTON Figure 1. Anatomy of the temporomandibular joint and the structures responsible for movement of the joint. The most common musculoskeletal conditions associated with temporomandibular disorders (TMD) are noted below: 1. Teeth and mandible. Dental occlusion – normal position is a 1- to 2-mm overbite. Bruxism – look for dental dam- age and enamel erosion. Mandibular function – opening less than 30 to 35 mm is considered abnormal. 2. Muscles of mastication. TMD findings may include spasm and/or tenderness to palpation of the masseter, temporalis and/or pterygoid muscles. The evaluation is best performed with clenched teeth. 3. Temporomandibular joint (TMJ). The TMJ is a gliding joint formed by the mandibular condyle and temporal bone fossa. The ligamentous capsule, articular disk, and retrodiskal tissue allow for smooth joint movement. Examine the joint by palpating anterior to the tragus bilater- ally. Clicking and popping may occur when the articular disk has moved anterior to the condylar head (click) but then is recaptured in proper position (pop). March 15, 2015 ◆ Volume 91, Number 6 www.aafp.org/afp American Family Physician 379 Temporomandibular Disorders Differential Diagnosis Evaluation Clinicians should be vigilant in diagnosing TMD in DIAGNOSIS patients who present with pain in the TMJ area. Condi- The diagnosis of TMD is based largely on history and tions that sometimes mimic TMD include dental caries physical examination findings. The symptoms of TMD or abscess, oral lesions (e.g., herpes zoster, herpes sim- are often associated with jaw movement (e.g., opening plex, oral ulcerations, lichen planus), conditions resulting and closing the mouth, chewing) and pain in the pre- from muscle overuse (e.g., clenching, bruxism, exces- auricular, masseter, or temple region. Another source of sive chewing, spasm), trauma or dislocation, maxillary orofacial pain should be suspected if pain is not affected sinusitis, salivary gland disorders, trigeminal neuralgia, by jaw movement. Adventitious sounds of the jaw (e.g., postherpetic neuralgia, glossopharyngeal neuralgia, clicking, popping, grating, crepitus) may occur with giant cell arteritis, primary headache syndrome, and TMD, but also occur in up to 50% of asymptomatic pain associated with cancer.11,12 The differential diagno- patients.1 A large retrospective study (n = 4,528) con- sis and associated clinical findings are presented in Table ducted by a single examiner over 25 years noted that the 1.11,12 TMD symptoms can also manifest in autoimmune most common presenting signs and symptoms were facial diseases, such as systemic lupus erythematosus, Sjögren pain (96%), ear discomfort (82%), headache (79%), and syndrome, and rheumatoid arthritis.11 jaw discomfort or dysfunction (75%).13 Other symptoms Table 1. Conditions That May Mimic Temporomandibular Disorders Condition Location Pain characteristics Aggravating factors Typical findings Diagnostic studies Management Dental conditions Caries Affected tooth Intermittent to Hot or cold stimuli Visible decay Radiography Extraction, filling continuous dull pain Cracked tooth Affected tooth Intermittent dull or Biting, eating Often difficult to visualize crack Radiography Possible extraction sharp pain Dry socket Affected tooth Continuous, deep, Hot or cold stimuli Loss of clot, exposed bone None Antibiotics, irrigation sharp pain Giant cell arteritis Temporal region Sudden onset of Visual disturbance, loss Scalp tenderness, absence of Erythrocyte sedimentation Corticosteroids continuous dull pain of vision temporal artery pulse rate, temporal artery biopsy Migraine headache Temporal region, Acute throbbing, Activity, nausea, Often normal, aversion during
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