Temporomandibular Joint Disorders JENNIFER J

Temporomandibular Joint Disorders JENNIFER J. BUESCHER, MD, MSPH, Clarkson Family Medicine Residency, Omaha, Nebraska

Temporomandibular joint disorders are common in adults; as many as one third of adults report having one or more symptoms, which include jaw or neck pain, headache, and clicking or grating within the joint. Most symptoms improve without treatment, but various noninvasive therapies may reduce pain for patients who have not experi- enced relief from self-care therapies. Physical therapy modalities (e.g., iontophoresis, phonophoresis), psychological therapies (e.g., cognitive behavior therapy), relaxation techniques, and complementary therapies (e.g., acupuncture, hypnosis) are all used for the treatment of temporomandibular joint disorders; however, no therapies have been shown to be uniformly superior for the treatment of pain or oral dysfunction. Noninvasive therapies should be attempted before pursuing invasive, permanent, or semi- permanent treatments that have the potential to cause irreparable harm. Dental occlusion therapy (e.g., oral splinting) is a common treatment for temporomandibular joint disorders, but a recent systematic review found insufficient evidence for or against its use. r me Some patients with intractable temporomandibular joint disorders os d h

Academy of Family Physicians.) ILLUSTRATION BY f ▲ Patient information: emporomandibular joint (TMJ) change and regenerate itself than the hya- A handout on temporo- disorder refers to a cluster of con- line cartilage of other synovial joints.5 The mandibular joint pain, ditions characterized by pain in synovial joint capsule and surrounding mus- written by the author of this article, is provided on the TMJ or its surrounding tissues, culature are innervated, however, and are page 1483. T functional limitations of the mandible, or thought to be the primary source of pain in clicking in the TMJ during motion.1,2 TMJ TMJ disorders. disorders are common and often self-limited The etiology of TMJ disorders remains in the adult population. In epidemiologic unclear, but it is likely multifactorial. Cap- studies, up to 75 percent of adults show at sule inflammation or damage and muscle least one sign of joint dysfunction on exami- pain or spasm may be caused by abnormal nation and as many as one third have at least occlusion, parafunctional habits (e.g., brux- one symptom.2,3 However, only 5 percent of ism [teeth grinding], teeth clenching, lip adults with TMJ symptoms require treatment biting), stress, anxiety, or abnormalities and even fewer develop chronic or debilitat- of the intra-articular disk. In recent years, ing symptoms.4 many of the theories about the development of TMJ disorders have been ques- Etiology tioned. Abnormal dental occlusion appears The TMJ is a synovial joint that contains an to be equally common in persons with articular disk, which allows for hinge and and without TMJ symptoms,1,6 and occlu- sliding movements. This complex combina- sal correction does not reliably improve tion of movements allows for painless and the symptoms or signs of TMJ disorders.2,7 efficient chewing, swallowing, and speak- Parafunctional habits have been thought ing.5 The articulating surfaces of the TMJ to cause TMJ microtrauma or masticatory are covered by a fibrous connective tissue; muscle hyperactivity8; however, these habits this avascular and noninnervated structure are also common in asymptomatic patients. has a greater capacity to resist degenerative Although parafunctional habits may play a

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. TMJ Disorders

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

TMJ disorders can be associated with other chronic pain syndromes or C 8 mental illness. Complicated cases may benefit from a multidisciplinary approach. TMJ disorders are commonly self-limited and should initially be treated C 16 with noninvasive therapies. Permanent occlusal adjustment and temporary dental splinting have not B 2, 7 been sufficiently studied to indicate benefit or harm for patients with TMJ disorders.

TMJ = temporomandibular joint. 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, see page 1435 or http://www.aafp.org/afpsort.xml.

role in initiating or perpetuating symptoms in trigger points may be determined by palpa- some patients, the cause-and-effect relation- tion of the masseter or sternocleidomastoid ship remains uncertain.8 muscles,9 which can be performed by plac- There is some evidence to suggest that ing a finger over the TMJ or into the ear anxiety, stress, and other emotional distur- canal while the patient opens and closes bances may exacerbate TMJ disorders, espe- the mouth. A clicking or popping sensation cially in patients who experience chronic that occurs during mouth opening may pain.8 As many as 75 percent of patients with indicate displacement of the intra-articular TMJ disorders have a significant psychologi- disk during mandibular movement.10 Pain cal abnormality.8 Recognition and treatment or swelling localized to the TMJ can indicate of concomitant mental illness is important intra-articular inflammation. Clicking is a in the overall approach to management of common symptom and is part of the diag- chronic pain, including pain caused by TMJ nostic criteria for TMJ disorders; however, disorders. joint sounds do not necessarily correlate with pain severity or functional limitation. Diagnosis Therefore, the absence of clicking sounds clinical examination is not a reliable symptom to use in deter- Common symptoms of TMJ disorders mining whether the patient has responded include jaw pain, limited or painful jaw to treatment.8 Absence of pain, improved movement, headache, neck pain or stiff- function, and normal quality of life are more ness, clicking or grating within the joint, appropriate markers of treatment success. and, occasionally, an inability to open the mouth painlessly.2,4 Most adults with these differential diagnosis symptoms do not seek medical or dental The differential diagnosis for orofacial pain is treatment. It is not clear which symptoms are listed in Table 1.4,11 TMJ disorders can cause more common in which TMJ disorders; how- referred pain, particularly undifferentiated ever, it is generally assumed that joint clicking headache.8 Some studies have shown that as or grating signifies intra-articular derange- many as 55 percent of patients with chronic ment whereas headache, neck pain, or painful headache who were referred to a neurologist jaw movement suggests a muscular problem. were found to have significant signs or symp- Examination of the TMJ and masticatory toms of TMJ disorders.12 Educating patients muscles should include careful palpation of on self-care techniques and referral for non- all structures. Myospasm and myofascial invasive treatment should be considered in

1478 American Family Physician www.aafp.org/afp Volume 76, Number 10 ◆ November 15, 2007 Table 1. Differential Diagnosis of Orofacial Pain

Condition Symptoms Signs

Dental pathology Tooth abscess Pain with chewing over Visible tooth decay; fluctuance along gum affected tooth line; pain with palpation over the tooth Wisdom tooth eruption Dull ache behind posterior Tenderness to palpation over emerging molars tooth Infection or inflammation Herpes zoster and Prodrome of pain followed Vesicular rash in dermatomal postherpetic neuralgia by vesicular rash distribution, not crossing midline Mastoiditis Fever; otalgia Postauricular erythema and swelling; tenderness over mastoid process Otitis externa Pruritus, pain, and tenderness Erythema and edema of external of the external ear auditory canal Otitis media Fever; malaise; otalgia Tympanic membrane dull, bulging, erythematous; loss of landmarks on tympanic membrane Parotitis Fever; malaise; myalgia; pain Tenderness and induration over parotid over parotid gland gland Sialadenitis Pain and swelling of involved Tenderness, induration, and/or erythema salivary gland of salivary gland; usually unilateral Trigeminal neuralgia Paroxysmal, unilateral Examination generally normal lancinating pains in trigeminal nerve distribution

Information from reference 4 and 11.

patients with chronic undifferentiated head- origin of the problem: articular disorders ache or headache that is not responding to and masticatory muscle disorders. Articu- standard treatment. lar disorders include the articular surface, intra-articular disk, or articulating bones.8,11 classification Masticatory muscle disorders are problems Research has been hindered by the lack of within the muscles surrounding the TMJ. clear diagnostic criteria for TMJ disorders; Accurate recognition of the origin of pain, however, two groups have developed diag- either intra-articular or muscular, may help nostic classification systems. The American the physician recommend an initial therapy; Academy of Orofacial Pain published a diag- however, it is not clear which noninvasive nostic classification system in 1995.8 Also, therapies work best.8 the Research Diagnostic Criteria for Tem- poromandibular Disorders (RDC/TMD) diagnostic testing tool was created and validated by the Inter- Diagnostic testing and radiologic imaging of national Consortium for RDC/TMD-based the TMJ have uncertain usefulness and gen- Research.13 These two classification systems erally should only be used for the most severe are not identical, but are substantially simi- or chronic symptoms.8 Local anesthetic nerve lar.14 The length and in-depth nature of the blocking can be helpful in differentiating RDC/TMD make this instrument impracti- whether orofacial pain originates from the cal for daily use in the family physician’s TMJ capsule or from associated muscular office; therefore, it will not be discussed in structures. Sensory innervation of the TMJ this article. is delivered primarily through the auriculo- An abbreviated version of the diagnostic temporal branch of the third division of the classification system developed by the Amer- trigeminal nerve (Figure 1).5,15 Patients who ican Academy of Orofacial Pain is shown in do not experience pain relief from diagnostic Table 2.8 TMJ disorders are separated into nerve blocking should be evaluated for other two main categories based on the anatomic causes of orofacial pain.5

November 15, 2007 ◆ Volume 76, Number 10 www.aafp.org/afp American Family Physician 1479 TMJ Disorders

Treatment Table 2. Diagnostic Classification of TMJ Disorders For most patients, the signs and symptoms of TMJ disorders improve over time with or with- Articular disorders of the TMJ out treatment. As many as 50 percent of patients Ankylosis improve in one year and 85 percent improve Congenital or developmental disorders completely in three years.16 Interventions that Aplasia, hyperplasia, or hypoplasia of the cranial bones or mandible change the anatomy of the joint, invade the Neoplasia of the TMJ or associated structures integrity of the joint space, or manipulate the Disk derangement disorders jaw have the potential to cause harm and have Articular disk displacement with or without reduction not been shown to improve symptoms. There- Fracture of the condylar process fore, self-care and noninvasive treatments are Inflammatory disorders good options and should be attempted before Synovitis, capsulitis, polyarthritides including the TMJ invasive or permanent therapies, such as ortho- Osteoarthritis dontics or surgery, are recommended.16 TMJ dislocation Masticatory muscle disorders self-care Local myalgia (unclassified) There is little evidence to suggest that any Myofascial pain TMJ disorder treatment modality is superior Myofibrotic contracture to any other, although it is generally accepted Myositis that self-care and behavioral interventions Myospasm should be encouraged for all patients, regard- Neoplasia less of which therapies are considered.8 Pro- viding a few simple exercises, behavioral TMJ = temporomandibular joint. instructions, and reassurance are important Information from reference 8. steps when treating the average patient with new or intermittent symptoms.

noninvasive therapy Many noninvasive therapies are commonly Superficial temporal artery used for the treatment of TMJ disorders. The disciplines of medicine, dentistry, physical therapy, and psychology can all provide Mandibular condyle effective treatment. Several available therapies are listed in Table 3.8,17 Because most Facial nerve patients with TMJ disorders improve with or without treatment, these conservative thera- Auriculotemporal nerve pies should be encouraged before invasive treatments are considered. k c pharmacologic intervention ussi -R ss e r Pharmacologic interventions similar to those K l e a for other musculoskeletal disorders are a ch Mi treatment option. Acetaminophen and non by steroidal anti-inflammatory drugs can help Superficial temporal vein with acute and chronic pain. For muscle spasm llustration I and chronic bruxism, muscle relaxants or Figure 1. Anatomy of the temporomandibular joint and associated benzodiazepines may be necessary if conserva- structures. For a diagnostic anesthesia block, use a small needle (25 to tive relaxation techniques fail. Tricyclic anti 30 gauge) to inject 0.5 cc of a short-acting anesthetic approximately 0.50 to 0.75 inches below the skin just inferior and lateral to the man- depressants may help with pain, including pain 4,8,16 dibular condyle.15 Always aspirate before injecting to ensure the needle from nighttime bruxism. Antidepressants is not in an artery or vein. that are used in the treatment of chronic pain

1480 American Family Physician www.aafp.org/afp Volume 76, Number 10 ◆ November 15, 2007 Table 3. Noninvasive Therapies for TMJ Disorders

Alternative therapies Physical therapy modalities Acupressure Biofeedback syndromes might also be beneficial in the Acupuncture Iontophoresis treatment of chronic TMJ disorders. However, Hypnosis Phonophoresis care should be used when prescribing selective Massage Superficial or deep heat serotonin reuptake inhibitors because there Dental procedures Therapeutic exercise have been rare case reports of selective sero- Temporary occlusal therapy Lateral jaw movement 18 tonin reuptake inhibitor-induced bruxism. Protrusive jaw movement Medical interventions Resisted closing intra-articular injections Intra-articular corticosteroid or anesthetic injection Resisted opening Intra-articular injections of the TMJ with Myofascial trigger-point injection Tongue-up exercise local anesthetics or corticosteroids can be Pharmacologic treatment Transcutaneous electrical nerve used for the treatment of inflammation within stimulation Acetaminophen the TMJ capsule.8 Intra-articular injection Anxiolytics Psychological interventions should only be used for severe acute exacer- Benzodiazepines Cognitive behavior therapy bations or after conservative therapies have Muscle relaxants Relaxation techniques been unsuccessful.8 Repeated intra-articular Nonsteroidal anti-inflammatory Stress management corticosteroid injections are not recom- drugs mended. A recent systematic review found Tricyclic antidepressants insufficient evidence to encourage the use of intra-articular hyaluronate for the treatment TMJ = temporomandibular joint. 19 of TMJ pathology. Local anesthetics and Information from references 8 and 17. botulinum toxin (Botox) can also be used in myofascial trigger-point injections for the treatment of chronic bruxism.8,16,20 and occluding splint therapy for treatment of TMJ disorders.2,7 There was insufficient dental occlusion therapy evidence to show benefit or harm with either Dental occlusal splinting and perma- treatment.2,7 Also, several trials comparing nent occlusal adjustment have been the occluding and nonoccluding splint therapy mainstays of TMJ disorder treatment for have shown no significant differences in years, although there is no clear evidence long-term treatment outcomes.23 Occlusal that malocclusion of the upper and lower adjustment, either permanent or temporary, teeth causes TMJ pain.8 Two main types can still be an appropriate treatment for of splinting are available: occluding and dental pathology, but its role in the primary nonoccluding. Occluding splints, also called treatment of TMJ disorders is uncertain.8 stabilization splints, are specially fabricated to improve the alignment of the upper and manual reduction in acute disk displacement lower teeth.20-22 Nonoccluding splints, also called simple splints, primarily open the Acute anterior displacement of the intra- jaw, release muscle tension, and prevent articular disk is a rare condition that causes teeth clenching.20-22 Occluding splints need the jaw to lock in the open position. This can to be fabricated and adjusted by a trained lead to painful inflammation in the articu- dentist and may cost several hundred dollars lar capsule and can inhibit swallowing and in overall treatment costs.12 Nonoccluding eating. Most patients with acute locking of splints are typically made of a soft vinyl and the jaw have a history of episodic locking, a are easier and cheaper to fabricate. Inex- noticeable click with chewing, or a habit of pensive versions can usually be purchased teeth clenching.10 Disk displacement should at local pharmacies.22 Permanent occlusal be reduced as soon as possible. adjustment can be obtained through ortho- If the patient is unable to reduce the dis- dontics or by grinding down the superficial placement by laterally moving the mandible tooth enamel to improve occlusion.8 and opening the mouth wide, manual reduc- The Cochrane Collaboration recently tion should be attempted. Manual reduc- reviewed permanent occlusal adjustment tion of the disk can usually be achieved by

November 15, 2007 ◆ Volume 76, Number 10 www.aafp.org/afp American Family Physician 1481 TMJ Disorders

inserting the thumb into the patient’s mouth, 7. Al-Ani MZ, Davies SJ, Gray RJ, Sloan P, Glenny AM. Stabilisation splint therapy for temporomandibular pain grasping under the chin, and simultane- dysfunction syndrome. Cochrane Database Syst Rev ously pushing down on the posterior teeth 2004;(1):CD002778. and pulling up on the chin. The mandibu- 8. Okeson JP, for the American Academy of Orofacial lar condyle will be distracted downward, Pain. Orofacial Pain: Guidelines for Assessment, Diag- nosis, and Management. Chicago, Ill.: Quintessence allowing the disk to move posteriorly into Pub, 1996. 10 place. The patient’s head should be stabi- 9. Friction JR, Gross SG. Muscle disorders. In: Pertes RA, lized, either by the examiner’s opposite hand Gross SG. Clinical Management of Temporomandibular or a headrest or wall. A local anesthetic or Disorders and Orofacial Pain. Chicago, Ill.: Quintessence Pub, 1995:91-108. intravenous benzodiazepine may be used to 10. Pertes RA, Gross SG. Disorders of the temporoman- decrease pain and relax severe spasm before dibular joint. In: Pertes RA, Gross SG. Clinical Manage- manual reduction. If the reduction is not ment of Temporomandibular Disorders and Orofacial successful, the patient should be evaluated Pain. Chicago, Ill.: Quintessence Pub, 1995:69-89. 11. Pertes RA, Bailey DR. General concepts of diagnosis and by an oral surgeon as soon as possible. treatment. In: Pertes RA, Gross SG. Clinical Manage- ment of Temporomandibular Disorders and Orofacial The author thanks Mark Lane for his assistance in the Pain. Chicago, Ill.: Quintessence Pub, 1995:59-68. preparation of the manuscript. 12. Wright EF, Clark EG, Paunovich ED, Hart RG. Headache improvement through TMD stabilization appliance and self-management therapies. Cranio 2006;24:104-11. The Author 13. International Consortium for RDC/TMD-Based jennifer j. buescher, md, msph, is the education Research. Accessed May 4, 2007, at http://www.rdc- director at Clarkson Family Medicine Residency, a com- tmdinternational.org. munity-based residency program in Omaha, Neb. She 14. John MT, Dworkin SF, Mancl LA. Reliability of clinical tem- received her medical degree from the University of poromandibular disorder diagnoses. Pain 2005;118:61-9. Chicago (Ill.) Pritzker School of Medicine, and completed 15. DuPont JS Jr. Simplified anesthesia blocking of the tem- a residency and faculty development fellowship at the poromandibular joint. Gen Dent 2004;52:318-20. University of Missouri-Columbia. 16. American Society of Temporomandibular Joint Address correspondence to Jennifer J. Buescher, MD Surgeons. Guidelines for diagnosis and manage- MSPH, Clarkson Family Medicine Residency, 4200 ment of disorders involving the temporomandibular Douglas, Omaha, NE 68131 (e-mail: jbuescher@nebraska joint and related musculoskeletal structures. Cranio med.com). Reprints are not available from the author. 2003;21:68-76. 17. Mannheimer JS. Overview of physical therapy modalities and procedures. In: Pertes RA, Gross SG. Clinical Man- REFERENCES agement of Temporomandibular Disorders and Orofa- cial Pain. Chicago, Ill.: Quintessence Pub, 1995:227-44. 1. Dworkin SF, Huggins KH, LeResche L, Von Korff M, Howard J, Truelove E, et al. Epidemiology of signs and 18. Gerber PE, Lynd LD. Selective serotonin-reuptake inhibi- symptoms in temporomandibular disorders: clinical tor-induced movement disorders. Ann Pharmacother signs in cases and controls. J Am Dent Assoc 1990; 1998;32:692-8. 120:273-81. 19. Shi Z, Guo C, Awad M. Hyaluronate for temporoman- 2. Koh H, Robinson PG. Occlusal adjustment for treating dibular joint disorders. Cochrane Database Syst Rev and preventing temporomandibular joint disorders. 2003;(1):CD002970. J Oral Rehabil 2004;31:287-92. 20. Shankland WE II. Temporomandibular disorders: stan- 3. Rutkiewicz T, Kononen M, Suominen-Taipale L, Nord- dard treatment options. Gen Dent 2004;52:349-55. blad A, Alanen P. Occurrence of clinical signs of tem- 21. Conti PC, dos Santos CN, Kogawa EM, de Castro poromandibular disorders in adult Finns. J Orofac Pain Ferreira Conti AC, de Araujo Cdos R. The treatment 2006;20:208-17. of painful temporomandibular joint clicking with oral 4. Hentschel K, Capobianco DJ, Dodick DW. Facial pain. splints: a randomized clinical trial. J Am Dent Assoc Neurologist 2005;11:244-9. 2006;137:1108-14. 5. Pertes RA, Gross SG. Functional anatomy and biome- 22. Truelove E, Huggins KH, Mancl L, Dworkin SF. The effi- chanics of the temporomandibular joint. In: Pertes RA, cacy of traditional, low-cost and nonsplint therapies for Gross SG. Clinical Management of Temporomandibular temporomandibular disorder: a randomized controlled Disorders and Orofacial Pain. Chicago, Ill.: Quintessence trial. J Am Dent Assoc 2006;137:1099-107. Pub, 1995:1-12. 23. Wassell RW, Adams N, Kelly PJ. The treatment of tem- 6. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, poromandibular disorders with stabilizing splints in orthodontic treatment, and temporomandibular disor- general dental practice: one-year follow-up. J Am Dent ders: a review. J Orofac Pain 1995;9:73-90. Assoc 2006;137:1089-98.

1482 American Family Physician www.aafp.org/afp Volume 76, Number 10 ◆ November 15, 2007