Temporomandibular Joint Disorder (TMD)

Akanksha Samal, DO
BASICS
DESCRIPTION
Syndrome characterized by
Pain and tenderness involving the muscles of mastication and surrounding tissues
Sound, pain, sti
Limitation of mandibular movement with possible locking or dislocation
Recent research suggests that TMD is a complex disorder with multiple causes consistent with a
biopsychosocial model of illness.
System(s) a
Synonym(s)\: TMJ syndrome; TMJ dysfunction; myofascial pain-dysfunction syndrome; bruxism; orofacial
pain
EPIDEMIOLOGY
Incidence
Annual
Peak incidence in ages 30 to 50 years
Prevalence
6-12% in both adults and older children
2\:1 female\:male
Up to 1/2 the population may have 1 + symptom of TMD, but most are not limited by symptoms, and
\<1\:4 seek medical or dental treatment.
ETIOLOGY AND PATHOPHYSIOLOGY
Multifactorial pathophysiology\: anatomic, behavioral, emotional, and cognitive
The American Academy of Orofacial Pain categorizes TMD according to three anatomic origins of pain.The change in name from TMJ to TMD emphasizes that many do not su
Muscle disorders involving the muscles of mastication
Occlusomuscular dysfunction (bruxism)
Masticatory muscle spasm
Myositis
Myo
Poorly
Contracture
Neoplasia
Articular disorders of the joint
Congenital disorders
In
Avascular necrosis (rare)
TMJ disk derangement, osteoarthritis
Hyper- or hypomobile TMJ
TMJ trauma\: condylar fractures, dislocation
Cranial bone disorder including the mandible
Congenital and developmental disorders
Acquired disorders (fracture, neoplasm)
Current consensus is that TMD is not only a local condition, so much as a family of complex disorders
that can lead to chronic pain, and often overlap with other chronic pain conditions that re
sensitization.
OPPERA study (Orofacial Pain\: Prospective Evaluation and Risk Assessment) is assessing the
heterogeneity in these disorders.
Genetics
Research is ongoing in gene polymorphisms associated with TMD and other pain disorders. The catechol O-
methyltransferase (COMT) gene is thought to be associated with changes in pain responsiveness.
RISK FACTORS
Trauma to the face, jaw, and neck, including cervical whiplash injuries and hyperextension of jawRheumatologic and degenerative conditions involving the TMJ
Psychosocial stress and poor adaptive capabilities
Repetitive microtrauma from dental malocclusion, including inappropriate dental treatment
Inconsistent association with bruxism and jaw/teeth clenching
Hormonal contraceptive use
GENERAL PREVENTION
Elimination of tension-causing oral habits
Reduction in overall muscle tension
COMMONLY ASSOCIATED CONDITIONS
Craniomandibular disorders, somatization disorder, somatoform pain disorder, other chronic pain
syndromes,
disturbance, tobacco use
DIAGNOSIS
TMD is a clinical diagnosis, and localized pain is the unifying feature.
HISTORY
Facial and/or TMJ pain
Locking/catching of jaw; decreased range of motion
Noises\: clicking, grinding, popping of TMJ
Headache, earache, neck pain
PHYSICAL EXAM
Muscle tenderness and restricted pain-free jaw opening
Check facial symmetry, muscle hypertrophy, and intraoral exam including tooth wear.
Palpation of muscles of mastication may reproduce pain.
There may be tenderness over the TMJ.
Test jaw range of motion (opening, closing, lateral, protrusive) and masticatory muscle strength.Maximal (pain free) jaw opening with interincisal distance \<40 mm is suggestive of joint rather than
muscle pathology if accompanied by other signs and symptoms (normal 35 to 55 mm).
Deviation to the a
Clicking or crepitus of jaw with opening
DIFFERENTIAL DIAGNOSIS
Condylar fracture/dislocation
Trigeminal neuralgia
Dental or periodontal conditions
Neoplasm of the jaw, orofacial muscles, or salivary glands
Acute, nondental infection\: parotitis, sialadenitis, otitis, mastoiditis
Jaw claudication\: giant cell arteritis
Migraine or tension-type headache
Ramsay Hunt syndrome (zoster auricular syndrome)
DIAGNOSTIC TESTS & INTERPRETATION
Blood work only useful to rule out other conditions (CBC, CMP, ESR, CRP); not needed for diagnosis
Initial Tests (lab, imaging)
TMD is a clinical diagnosis based primarily on history and physical exam.
Poor correlation between pain severity and pathologic changes is seen in joint or muscle tissues. Consider
the following for traumatic, infectious, severe, or treatment-resistant cases, with MR or CT more useful as
part of surgical workup\:
Panoramic dental radiographs.
CT scan allows
US\: E
MRI\: noninvasive study for disc position; more sensitive than US; can help determine need for surgical
management
Diagnostic Procedures/Other
Local anesthetic nerve block can di
Test Interpretation
Positive
Condylar head displacement
Anterior disc displacement
Posterior capsulitis
Loosening of disc and capsular attachments
Chondroid metaplasia of disc leading to disc perforation and degeneration
TREATMENT
Signs and symptoms will abate without any interventions in most patients. 50% report improvement at 1
year and 85% by 3 years. With conservative therapy, symptoms resolve in 75% of cases within 3 months.
Only 5-10% will require surgical intervention.
Patient education and setting expectations are important because there is no “cure” for TMD, yet most
patients will improve with limited interventions.
Psychosocial interventions, including cognitive-behavioral therapy with or without biofeedback (1)[A]
Behavior modi
nonfood items as well as potential strain from playing musical instruments that stress or strain the jaw
(wind, brass, or string) (1)[A]
Therapeutic exercises, especially if displacement is present, including formal physical therapy
Occlusal adjustment cannot be recommended for the management or prevention of TMD because there is
an absence of evidence from RCTs that occlusal adjustment treats or prevents TMD (2).
Insu
TMD.
The American Dental Association recommends a “less is often best” stepwise approach and o
following stepwise progression for therapy\:
Eating softer foods
Avoiding chewing gum and nail biting
Modifying pain with heat or ice
Relaxation techniques including meditation and biofeedbackExercises to strengthen jaw muscles
Medications
Night guards and orthotics
MEDICATION
First Line
NSAIDs\:
Naproxen\: 500 mg BID stronger evidence than for other NSAIDs
Ibuprofen, if osteoarthritis is suspected
Topical diclofenac if oral medication is contraindicated
Gabapentin\: Titrate up to 1,800 mg/day divided.
Acetaminophen
Second Line
Cyclobenzaprine 10 mg nightly more e3)[B]
Tricyclic antidepressants\: nortriptyline or amitriptyline
Acupuncture and dry needling can reduce pain (2).
Opiates should be reserved for perioperative or severe or recalcitrant cases (4)[B].
DMARDs may bene
Ine4)[B]
The following medications when compared with placebo in RCTs were shown to be ine
improving pain and should not be used for the treatment of TMD\:
Benzodiazepines
Topical capsaicin
Celecoxib
ADDITIONAL THERAPIES
Joint and muscle injections
A systematic review of arthrocentesis with injection of hyaluronic acid and platelet rich plasma showedno clinical improvement (5).
Steroids given >3 times annually may accelerate degenerative changes.
Injections into inferior space or double spaces have better e
A systematic review evaluating botulinum toxin type A (Botox) injections revealed mixed results (2).
For advanced structural abnormalities, referral for discectomy, arthroplasty, or joint replacement can be
considered; however, strong evidence is lacking for lavage or surgical treatments over conservative
management (2).
COMPLEMENTARY & ALTERNATIVE MEDICINE
Glucosamine may be e4)[B].
Multiple electronic diagnostic and treatment modalities are currently marketed to patients; however, the
scienti
this time.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Relax jaw by disengaging teeth.
Avoid wide, uncontrolled opening, such as yawning.
Trial of soft diet
Stress management and behavior modi
Be aware of any teeth-clenching or grinding habits.
Patient Monitoring
Ongoing assessment of clinical response to conservative therapies (NSAIDs, behavior modi
occlusal splints) is necessary.
Surgical procedure (arthroplasty, joint replacement) to correct disc displacement or replace a damaged
disc may be indicated only if the patient has not responded to conservative treatment.
DIET
Soft diet to reduce chewing
PROGNOSISWith conservative therapy, symptoms resolve in 75% of cases within 3 months.
Patients bene3)\:
Restoration of normal muscle function
Pain control
Stress management
Behavior modi

COMPLICATIONS

Secondary degenerative joint disease
Chronic TMJ dislocation
Loss of joint range of motion
Depression and chronic pain syndromes
Secondary headache disorder
REFERENCES
1. Aggarwal VR, Lovell K, Peters S, et al. Psychosocial interventions for the management of chronic
orofacial pain. Cochrane Database Syst Rev. 2011;(11)\:CD008456.
2. Gil-Martínez A, Paris-Alemany A, López-de-Uralde-Villanueva I, et al. Management of pain in patients
with temporomandibular disorder (TMD)\: challenges and solutions. J Pain Res. 2018;11\:571-587.
3. Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician.
2015;91(6)\:378-386.
4. Mujakperuo HR, Watson M, Morrison R, et al. Pharmacological interventions for pain in patients with
temporomandibular disorders. Cochrane Database Syst Rev. 2010;(10)\:CD004715.
5. Derwich M, Mitus-Kenig M, Pawlowska E. Mechanisms of action and e
corticosteroids and platelet-rich plasma in the treatment of temporomandibular joint osteoarthritis—a
systematic review. Int J Mol Sci. 2021;22(14)\:7405. Full Text
See Also
Headache, TensionCodes
ICD10
M26.60 Temporomandibular joint disorder, unspeci
M26.62 Arthralgia of temporomandibular joint
M26.63 Articular disc disorder of temporomandibular joint
Clinical Pearls
TMD refers to a number of potential underlying joint and muscle conditions involving the jaw.
Characteristics of all conditions are pain and functional limitation.
TMD is a clinical diagnosis; imaging and labs are often of limited utility.
Cognitive-behavioral therapy reduces pain, depression, and limitation of function.
Exercises may improve function and pain.
Evidence is lacking to support occlusion correction or splinting.
Naproxen, gabapentin, topical methyl salicylate, glucosamine, amitriptyline, acupuncture, and botulinum
toxin injections have some evidence of e