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Temporomandibular Joint Syndrome


Temporomandibular Joint Syndrome

Article Author:
Kushagra Maini
Article Editor:
Anterpreet Dua
Updated:
11/17/2020 12:48:29 PM
For CME on this topic:
Temporomandibular Joint Syndrome CME
PubMed Link:
Temporomandibular Joint Syndrome

Introduction

The temporomandibular joint syndrome is also known as temporomandibular disorder (TMD) is a common type of musculoskeletal disorder in the orofacial region involving the masticatory muscles, temporomandibular joint (TMJ) and associated structures. The typical features are pain in TMJ, restriction of mandibular movement, TMJ sound, and facial deformities.

TMJ Anatomy

The temporomandibular joint (TMJ), also known as ginglymoarthrodial joint, is a bi-arthrodial joint that is composed of the temporal bone's articular surface and the head of the mandible, enclosed in a fibrous capsule. The joint is separated into two synovial joint cavities by an articular disc. The anterior portion of the disc is attached to the joint capsule, articular eminence, and the upper area of the lateral pterygoid. The posterior portion relates to the mandibular fossa and the temporal bone, also referred to as the retrodiscal tissue. The three major ligaments, temporomandibular, stylomandibular, and sphenomandibular ligaments, stabilize the TMJ.

Arterial blood supply to the TMJ is primarily from the superficial temporal and maxillary branches of the external carotid. Other contributing branches include the anterior tympanic, deep auricular, and ascending pharyngeal arteries. The sensory nerve supply to the TMJ is by the auriculotemporal and masseteric branches of the mandibular nerve (V3), which is a branch of the trigeminal nerve.

Etiology

TMD etiology is multifactorial. Various theories, such as mechanical displacement, trauma, biomedical, osteoarthritis, muscle theory, neuromuscular, psychophysiological, psychosocial theory, have been proposed to cause TMD.[1][2][3][2][1] Several factors, either alone or in combinations, are responsible for TMD.[4][5] Due to multifactorial etiology, the most common factors are: 

  1. Predisposing factors -The factors that increase the risk of TMD or orofacial pain. It further subdivides into systemic, psychologic, structural, and genetic factors.
  2. Initiating factors -The factors that cause the onset of disorder such as trauma, overloading of joint structure such as parafunctional habits.
  3. Perpetuating factors -The factors that interfere with healing or complicate management such as mechanical, muscular stress, and metabolic problems.

The factors can influence each other or act together.

Epidemiology

Epidemiological studies from around the world confirm a very high prevalence of TMD dysfunction. Reports indicate that 39.2% have at least one symptom of TMD. The incidence rate is 3.9% among adults and 4.6 % among adolescents. Symptoms of TMD are common in all age groups. Older age groups demonstrate slightly more symptoms than the young.  Women are affected more than men, observed as 2 to 1 in population-based studies, and 4 to 1 in clinical settings. No gender differences have appeared in children, but the ratio becomes 2 to 1 in young adults (female to male ratio).[6]

Pathophysiology

Classification:

Farrar (1972), Block (1980), Welden. E. Bell (1986) AACD (1990), Edmond truelove, SamuelDwork and Linda LeResche, Suvinen et al. (2005), Stegenga (2010), Machado et al. (2012), Peck et al. ( 2014), Schiffman et al. ( 2014) proposed various systems of classification of TMD [7]. The Schiffman classification published the diagnostic criteria (DC)/TMD represents the evolution of widely accepted research diagnostic criteria of TMD in 1992. It is a two-axis system physical axis and psychosocial diagnosis. The physical system divides into the most common joint problems and muscle conditions. The classification proposes a more standardized, reliable self-reporting questionnaire, clinical examination systems, scores, and decision trees. It integrates biophysical diagnosis to disability index, which measures the impact of pain on patient behavior. The classification depends on clinical examination procedures; the assessment of specific disorders is best through imaging procedures not included in the classification. The most accepted classification that aids in the understanding of the pathophysiology is Perk and Schiffman et al. (2014)[8] and Bell (1986).

Weldon Bell presented a classification that logically categorizes these disorders, and the American Dental Association adopted it with few changes. The use of such a logical classification system benefits diagnostic capability as well as communication within the profession. All temporomandibular joint disorders divide into four broad categories having similar characteristics as follows:

I. Masticatory Muscle Disorders:

The most common type of pain observed in patients is pain in the masticatory muscles when swallowing, speaking, and chewing. Pain increases with palpation or with manipulation of muscles. It is associated with restricted mandibular movements.

II.Temporomandibular Joint Disorders:

Temporomandibular joint disorders subdivide into three major categories:

  1. Derangement of the condyle-disc complex:

The derangement of the condyle disc complex arises due to breakdown in the rotational function of the disc. This condition can result from the lengthening of ligaments (discal collateral and inferior retro-discal ligaments) or thinning of the posterior disc border. The contributing factors can be micro or macro trauma. The derangements are of three types:

     i. Disc displacements:

In the event of constant stretching of the inferior retro-discal lamina and the discal collateral ligament, the discs get positioned anteriorly due to the function of the superior lateral pterygoid muscle. The changes in disc and muscle position lead to a translator shift of the condyle during the opening. The movement is associated with click or sound in either or both during the opening and closing of the mandible.

     ii. Disc dislocation with reduction:

The disc displacement can either lead to partial or complete disarticulation of the disc from discal space in condyle – disc assembly leading to disc dislocation. The dislocation is reduced in situations when the patient can manipulate the mandible to reposition the condyle to the disc position. The condition clinically presents with a controlled range of jaw opening and jaw deviation in the process of opening the mouth. The reduction of the disc creates loud pop during disc reposition. The interincisal distance of disc reduction during opening is greater than when the disc is re dislocation during the closure.

     iii. Disc dislocation without reduction:

The repositioning of the disc can become problematic due to the loss of elasticity in the superior retro-discal lamina. This situation causes forward translation of the condyle forcing the disc in front of the condyle. It presents as a locked jaw in closure, and a normal opening is not achievable. Clinically it is represented as difficulty in maximum opening. The mandibular opening is around 25 to 30 mm, deflects towards the involved joint, and associated with pain. The bilateral manipulation technique of loading the joint is painful due to the position of the condyle in the retro-discal tissues. 

    2. Structural incompatibility with articular surfaces:

The disorder results from changes in the smooth sliding surfaces of the TMJ. The alteration causes friction, stickiness, and inhibits joint function. The structural incompatibility classifies as a deviation in form, adhesions, subluxation, and spontaneous dislocation

     i. Deviation in form:

The physiological, aging, or minor degenerative alterations in the condyle, disc, and fossa can cause deviations and dysfunction, which significantly affects the mandibular movements.

     ii. Adherences and adhesions:

An adherence represents a brief hold of the articular surfaces. Adhesion can happen between the condyle- disc or amidst the disc or between the disc-fossa. Adhesions are created by the development of fibrous connective tissue or due to loss of lubrication between the structures. It characteristically demonstrates restriction in the normal translation of the condyle movement with no pain. In chronic situations, the patient senses an inability to get the teeth back to occlusion during the closure.

     iii. Subluxation and luxation (hypermobility):

It is a non-pathologic condition, repeatable clinical phenomena characterized by a sudden forward movement of the condyle past the crest of the articular eminence during the final stages of mouth opening. The steep, short posterior slope of the articular eminences and the longer anterior slope, which is more superior to the crest, causes the condyle to subluxate. The examiner can witness it by requesting the patient to open wide, and this also creates a small void or depression behind the condyle.

    iv. Dislocations:

Dislocations are the result of hyperextension of the TMJ. It causes the fixing of the joint in an open position during the opening of the mouth. Open-lock prevents the translation of the mandible. The imaging displays the posterior position of the disc in relationship to the condyle. The anterior teeth are usually separated, and the posterior teeth closed, the patient shall find difficulty in closing the mouth, and pain is associated with it.  

     3. Inflammatory disorders of the TMJ:

The joint disease of inflammatory origin characteristically presents with deep continuous pain that commonly gets accentuated on functional movement.  The continuous pain can trigger secondary excitatory effects. It expressed as referred pain, sensitivity to touch, protective contraction, or a combination of these problems. Inflammatory joints also get classified according to the structures involved, such as synovitis, capsulitis, retro-discitis, and arthritis.

     i. Synovitis/capsulitis:

Trauma or abuse can cause inflammation of the synovial tissues (synovitis) and the capsular ligament (capsulitis). Clinically it is difficult to differentiate, and arthroscopy is useful for diagnosis. It presents as continuous pain, tenderness on palpation, and limited mandibular movement.

     ii. Retrodiscitis:

It is caused due to trauma or due to progressive disc displacement and dislocation. The patient complains of pain, which increases with clenching. Limited jaw movement, swelling of retro discal tissues, and acute malocclusion are associated with the disease.

    iii. Arthralgia

Pain originating in the joint that is affected by jaw movement, function, or para-function and replication of this pain occurs with provocative testing of the TMJ.

    iv. Arthritis

Pain originating in the joint with clinical characteristics of inflammation or infection over the affected joint that is edema, erythema, and/or increased temperature. Associated symptoms can include dental occlusal changes (e.g., ipsilateral posterior open bite if intraarticular with unilateral swelling or effusion). This disorder is also known as synovitis or capsulitis, although these terms limit the sites of nociception. TMD is a localized condition; there should be no history of systemic inflammatory disease.

a) Osteoarthritis :

It is an inflammatory disorder that arises due to an increased overload of the joint. The increased forces soften the articular surfaces and resorb the subarticular surface. The progressive loading and the subsequent regeneration causes loss of subchondral layer, bone erosion, and osteoarthritis. It is evidenced by pain in joints and increases with the jaw movements and associated with disc dislocation or perforation.

b) Osteoarthrosis:

Arthrosis is the adaptive unaltered arthritic changes of the bone due to decreased bone loading. It occurs after the overloading of the joint, mainly due to parafunctional activity and often associated with disc dislocation.

c) Systemic arthritis

 Several types of arthritides can affect the TMJ, including traumatic arthritis, infectious arthritis, and rheumatoid arthritis.

III. Chronic Mandibular Hypomobility:

It is a long term painless restriction of the mandible. Pain occurs only when using force to attempt opening beyond limitations. The classification of the condition is according to the cause, as ankylosis, muscle contracture, or coronoid process impedance.

IV. Growth Disorders:

TMDs resulting from growth disturbances may be the result of a variety of causes. The growth disturbances may be in the bones or the muscles. Common growth disturbances of the bones are agenesis (no growth), hypoplasia (insufficient growth), hyperplasia (excessive growth), or neoplasia (uncontrolled, destructive growth). Common growth disturbances of the muscles are hypotrophy (weakened muscle), hypertrophy (increased size and strength of the muscle), and neoplasia (uncontrolled, destructive growth). It results from deficiencies or alterations in growth that typically result from trauma.

History and Physical

History and examination of TMD

The objective of eliciting history and examination is to recognize the clinical signs and symptoms. The factors to be included in history are[9][10][11][12][13]:

1) Chief complaints that include:

  • Location, onset, and characteristic of pain
  • Aggravation and relieving factors
  • Past treatments if any and their result
  • Any other pain disorders.

2) Past medical and dental history 

3) General systematic assessment

4) Psychologic assessment

Physical examination findings of TMD include decreased range of motion, signs of bruxism, abnormal mandibular movements, tenderness of muscles of mastication, neck, and shoulder, pain with dynamic loading, and postural asymmetry. It is vital to perform an oral and dental examination to look for signs of tooth wear and a neurology examination to look for any cranial nerve abnormalities. A click, crepitus, or popping sensation which may accompany joint opening or closing may be associated with anterior disc displacement or osteoarthritis.[14] Careful palpation of masticatory muscles and surrounding neck muscles may be associated with myalgia, trigger points, myospasm, or referred pain syndrome.[15][16]

The following baseline records should normally be part of the workup for patients suspected of having a TMJ disorder:

  • Clinical examination
  • Radiographic examination of teeth and TMJ
  • Diagnostic casts

The initial and most helpful study in diagnosing TMD is plain or panoramic radiography, which may reveal acute fractures, arthritis, or disc displacements. Further imaging studies like computed tomography (CT) or magnetic resonance imaging (MRI) are beneficial in severe, chronic, or suspected structural abnormalities of TMJ.[17][18] Additionally, newer techniques of nerve blocks, botulinum toxin injections, arthrography, and mandibular motion data can prove to be of significant diagnostic benefit.

Evaluation

Signs and symptoms of TMD[19][20]:

1) Pain:

Pain from the TMJ and muscles of mastication is a common symptom. It can be constant or periodic dull ache over the joint, the ear, and temporal fossa. It is more observed during the mandibular movement or by palpation of the affected regions. The pain can be myogenic caused due to mechanical trauma and muscle fatigue. Articular pain arising due to inflammation of articular and periarticular tissues either by overloading, trauma, or degenerative changes.

2). Joint Sounds:

The two common joint sounds observed are clicking and crepitations.

Clicking is a sound of the short event observed during the mandibular movement caused by the uncoordinated movement of the condylar head and the articular disc. Crepitations are compound sounds that are caused by the roughened, irregular articular surfaces of the joint  and observed during mandibular movement

3). Limitation of Mandibular Movement:

The restrictions in movement of the mandible are observable either in all or in part of opening, closure, protrusion, and lateral movement. It can be due to muscular restriction, disc displacement, ligaments restriction.

4). Dislocation:

It is the displacement of the condyle from fossa, and the patient may be unable to close the mouth. The patient can reduce the dislocation himself or report to the clinician for reduction.

5). Dental Symptoms:

Tooth mobility, pulpitis, tooth wear are the commonest dental symptoms elicited in TMD patients.

6). Otologic Symptoms:

TMJ pain in the auricular regions is more noticeable posteriorly. Tinnitus, itching in the ear, and vertigo are other symptoms associated with auricular pain.

7). Recurrent Headaches:

Patients perceive the pain and tenderness of masticatory muscles along the temporal region as headaches. Additionally, it can correlate with other headaches, such as migraine pain.

Treatment / Management

Treatment of Temporomandibular disorders[21][22][23][22][24][25][24]:

The identification of the disorder and management could be a challenging task.  It is imperative to determine the disorder with adequate evidence before initiating the treatment. The treatment plan decision can be from among the various options available.

The first step in treating TMJ disorders is symptomatic care, which usually consists of (a) a soft diet, (b) mild inflammatory agents, (c) moist heat packs alternating with ice, and (d) voluntary disengagement of the teeth.

Further treatment modalities can group into definitive and supportive treatment.

 

1. Definitive treatment:

The definitive treatment identifies the disorder and treats the cause of the disorder. The various treatment methods are

a) Occlusal therapy:

The modifications in dental occlusion are the primary treatment method of TMD. This treatment focuses on altering the mandibular positioning. It identifies and removes derangements in occlusion and contact interference. It classifies as either reversible or irreversible occlusal therapy.

i) Reversible occlusal therapy:

CLinicians achieve this result with an occlusal splint that alters patient occlusion briefly. The splints are made of acrylic, fixed over the teeth of one arch. The creation of the opposing surface of the splint accounts for a new mandibular position. The mandible returns to the original position on discontinuation of the splint. A stabilizing splint is the commonest splint used. It aids in stabilizing the musculoskeletal position of the mandible.

ii) Irreversible occlusal therapy:

The occlusal surfaces are altered forever in irreversible occlusal treatment. The tooth interference or the default occlusal position of the teeth are identified and permanently changed either by selective grinding of the tooth surface or by tooth restorations.

b) Emotional stress therapy:

Generally, TMD is associated with the emotional and psychological state. Muscle activities become altered due to increased levels of emotional stress.

Stress management can be with patient behavioral therapy in the following ways:

i) Patient awareness:

The patient receives education regarding the relationship between stress and muscle hyperactivity. This understanding aids in better behavioral management and improves psychological health and the condition.

ii) Restrictive use:

In the majority of TMD situations, patients complain of pain in TMJ and restricted mandibular movement. The clinician should instruct the patient to move the mandible within a trouble-free range of motion, which promotes psychological health and pain disorder.

iii) Voluntary avoidance:

The teeth contact can trigger the pain in patients. The patients must try to reduce tooth contact time. Except during mastication, swallowing, and speaking, the clinician directs patients to disengage the tooth to diminish the pain or discomfort coercively. A simple exercise of lip puffing can voluntarily disengage teeth and enhance patient health.

iv) Relaxation therapy:

Relaxation is perceptive. Among the numerous relaxation techniques, patients are encouraged to follow one that suits them to relax the muscles and promote psychological health.  The stretch-relax procedure and progressive relaxation techniques are commonly followed and effective among TMD patients.

 

2. Supportive Therapy:

Patient symptom management is through supportive therapy. The cause of TMD may not be relieved with supportive treatment.

The following methods are the currently adopted approach for treating these patients:

 a) Pharmacologic therapy: Analgesics, Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anxiolytic agents, muscle relaxants, anti-depressants, local anesthetics can be either administered locally or systematically to reduce the patient symptoms. Typically, 10 to 14 days course of NSAIDs is the recommended course for acute pain. Muscle relaxants are an optional adjunct to treat myospasm. If a patient reports poor response in two to three weeks, tricyclic antidepressants (TCA) are another option, especially if the pain is associated with bruxism.[26][27][28] 

Invasive strategies include intra-articular long-acting corticosteroid or hyaluronic acid injections and trigger point botox injections. These interventions are recommended once conservative therapies have failed or in severe acute exacerbations. Intra-articular steroids are a recommended intervention for acute treatment of osteoarthritis of TMJ, but multiple doses can lead to the destruction of articular cartilage.[29][30] There is only limited evidence regarding the efficacy of hyaluronate injections in treating acute exacerbations.[31] Botulinum toxin injections only for painful trigger points or chronic bruxism, but a recent Cochrane study had inconclusive evidence for myofascial pain.[32][33]

 b) Physical therapy: Physical therapy is commonly advocated as an adjuvant to definitive treatment. Modalities used in physical therapy involve thermotherapy, coolant therapy, ultrasound, phonophoresis, iontophoresis, electro galvanic stimulation therapy, TENS, acupuncture, and cold laser. The commonly followed manual techniques are soft tissue mobilization, joint mobilization, muscle conditioning, resistance exercises, passive muscle stretching, assisted muscle stretching, and postural training.

Differential Diagnosis

Various other disorders can present as facial or ear pain or even headaches.  A thorough history and physical exam with basic labs like blood counts, kidney and liver function tests, and sedimentation rate help in localizing the lesion for most presentations of TMJ pain.[15][34]

  •  Common causes of facial pain include trigeminal, glossopharyngeal, or post-herpetic neuralgia, sinusitis, salivary gland disorders, and carotidynia.
  •  Common causes of headaches include migraines, cluster headaches, strokes, and temporal arteritis.
  •  Common causes of ear pain or stuffiness are middle ear infections, injuries, barotrauma, and Eustachian tube dysfunction. 

Prognosis

Most patients with TMJ pain have a favorable response to treatment, whereas a small number of patients develop refractory or persistent TMD. There are no known risk factors associated with chronic TMD. Recent data published did correlate heightened sympathetic tone with chronic TMJ pain.[35]

Complications

There are no reported complications. 

Consultations

Referral to an oral maxillofacial surgeon (OMFS) is the usual recommendation for:

1. Refractory TMD with no response to noninvasive or minimally invasive techniques like intraarticular injections, trigger point injections or botulinum toxin injections

2. Structural or articular abnormalities

Imaging is diagnostic for most structural abnormalities. Surgical techniques include arthroscopy, arthrocentesis, reconstructive jaw procedures, discectomy, and condylotomy.[36][37]

Deterrence and Patient Education

TMD conditions are among the most perplexing and intractable problems in clinical dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often accompanied by a restricted range of mandibular motion. Pain control is considered the primary goal of TMD management. Once pain control is accomplished, improvement and restoration of acceptable mandibular function are likely.

A thorough history and physical examination to arrive at the diagnosis are critical.

Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy, dental remedies, and psychological assistance, can lead to effective management and may curb the negative repercussions of TMD upon the quality of life and daily functioning.

Enhancing Healthcare Team Outcomes

TMD conditions are among the most perplexing and intractable problems in clinical dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often accompanied by a restricted range of mandibular motion. Pain control is considered the primary goal of TMD management. Once pain control is accomplished, improvement and restoration of acceptable mandibular function are likely.

A thorough history and physical examination to arrive at the diagnosis are critical.

It is essential to communicate and collaborate between providers, as most patients with TMD require a combined approach of both pharmacologic and non-pharmacologic measures, which can help reduce suffering and alleviate the maximal symptoms of TMJ disorder. The interprofessional team consists of primary care providers, dentists, oral surgeons, physical therapists, nurses, and pharmacists. Nurses often provide education, monitor patient response, and keep all team members updated on the patient's condition. Nurses also can serve as a coordination point between different members of the interprofessional healthcare team. Pharmacists provide instructions to patients about medications, reviewing dosing and side effects, and check for any potential drug interactions; reporting potential concerns to the team. [Level 5]

Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy, dental remedies, and psychological assistance, can lead to effective management and may curb the negative repercussions of TMD upon the quality of life and daily functioning.


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