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Temporomandibular
Joint Dysfunction |
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Overview |
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Definition |
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The temporomandibular joint (TMJ) is a synovial joint that involves the
masseter, medial pterygoid, and temporalis muscles of the lower jaw movement.
TMJ dysfunction, often simply but inaccurately referred to as TMJ,
characteristically involves face pain, clicking sounds in the TMJ, and limited
movement in the mandibular area. Terminology given to the condition has been
confusing and treatment of it diverse. Physicians do not appear to agree on
whether TMJ dysfunction should be treated by the medical provider, the dental
professional, or both. TMJ dysfunction has a prevalence rate of about 33% in the
general population. However, up to 75% percent of the population may have some
symptoms with only 5% to 25% seeking treatment. TMJ dysfunction affects people
of all ages and women only slightly more than men. |
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Etiology |
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Definitive etiology is unknown but probably multifactorial. Contributing
causes include the following.
- Malocclusion—controversial as a causal
factor
- Bruxism (jaw clenching)—leading to
masticatory muscle fatigue and spasm
- Disk derangement
- Trauma to the area
- Synovitis
- Psychophysiologic factors
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Risk Factors |
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- Women—seek treatment twice as often as
men
- Age 30 to 50
- Nutritional or metabolic disorders
- Chronic bruxism
- Occlusal problems
- Psychosocial stress—especially bereavement,
illness, divorce, moving; depression is a risk for chronicity
- Unfavorable incisor relationship—overbite,
overjet, negative overbite
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Signs and Symptoms |
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- Orofacial pain—usually a chronic, unilateral,
dull pain that may extend to the eyes and ears; worsens during mastication;
masticatory muscle tenderness
- Decreased mandibular range of
motion—especially in the morning; jaw may
lock
- Clicking and/or crepitus noises (however, up to 50% of the population
may have such noises without pain or other TMJ dysfunction symptoms)
- Headache—often chronic
- Earache, tinnitus, blocked sensations
- Neck pain
- Dizziness, vertigo
- Aggravated by occlusal problems
- Flattened molar prominences from chronic bruxism
- Chewing exacerbates all
symptoms
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Differential
Diagnosis |
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- Numerous other causes of head, neck, or ear pain (e.g., sinusitis,
acute otitis media, acute otalgia, parotitis)
- Neuralgias—trigeminal, herpes zoster,
geniculate
- Rheumatoid arthritis and osteoarthritis
- Condylar hyperplasia
- Gout, with accompanying tophi
- Odontogenic pain
- Ankylosing spondylitis
- Neoplasia
- Congenital disorders
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Diagnosis |
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Physical Examination |
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The muscles in the area of the TMJ may be palpated for tenderness and
fasciculations or spasms; palpate as the patient opens and closes jaw. Face is
checked for asymmetry or inflammation. Joint clicking or scraping sounds may be
audible. The patient's mandibular range of motion may be limited. The teeth may
show evidence of bruxism or jaw clenching, such as wear facets. A neurological
examination should be given if any signs of neurological dysfunction are evident
(e.g., numbness). |
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Pathology/Pathophysiology |
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- Limited mandibular range of motion: <50 mm opening, <10 mm
protusively and laterally
- Intracapsular diseases—infection, tissue, or
degenerative joint disease
- Spasms of the masseter and internal pterygoid muscles
- Nonserous inflammation from mechanical microlesions of interfibrillar
connective tissue
- Inflammation of articular and periarticular tissue
- Release of neuropeptides
- Osteoarthritic joint—irregular surfaces,
morphologic changes
- Anterior displacement of articular disk within joint, preventing
forward translation of mandibular
condyle
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Imaging |
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Unless there is suspicion of degenerative disease or disk derangement,
imaging should not be performed routinely. Imaging can reveal osseous tumors,
articular disk problems, condylar erosion, osteophytes, heterotopic bone, or
metastatic disease. Panoramic dental radiographs reveal occlusion or other
dental problems. Magnetic resonance imaging is the medium of choice for bony and
soft tissue visualization and determination of joint effusion, avascular
necrosis, or intracapsular TMJ disease. Arthrography is an invasive technique
but allows visualization of the condyle in relationship to the disk through
tomography recorded on video camera. |
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Other Diagnostic
Procedures |
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- Often diagnosed by a dentist
- History and physical examination of the masticatory
system
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Treatment Options |
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Treatment Strategy |
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Many primary physicians see TMJ dysfunction largely as a psychophysiologic
condition, while others evaluate it as a dental problem. TMJ dysfunction is
treated successfully in 75% of patients who employ multifaceted treatment plans.
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Drug Therapies |
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- Analgesics—aspirin or nonsteroidal
anti-inflammatory drugs—no significant long-term
benefits; patient-reported short-term benefit; gastrointestinal side
effects
- Minor tranquilizer/muscle relaxants—bedtime
use reduces spasms and pain; diazepam 2 mg every hour or as needed for three to
five days
- Intramuscular injections—local anesthetic,
longer periods of relief with repeated injections; 2% lidocaine hydrochloride
- Antidepressants—for refractory pain; e.g.,
nortriptyline 25 mg every hour or as needed
- Intra-articular cortisone
injections—intractable cases only, controversial; side
effects include infection, local structure damage, usual systemic
effects
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Surgical Procedures |
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- High intracapsular condylectomy, disk correction or replacement; when
all other measures have failed
- Arthroscopy—less invasive and provides good
symptom relief; low incidence of complications; long-term benefit unclear
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Complementary and Alternative
Therapies |
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The goal is to decrease inflammation and provide pain relief. Physical
approaches can be quite effective. Although research is scanty, a clinical trial
of CAM therapies seems reasonable, given the irreversibility of surgery.
Biofeedback may be efficacious in treating TMJ and in preventing
recurrence. |
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Nutrition |
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- Essential fatty acids regulate arachidonic acid metabolites to
decrease inflammation; 1,000 to 3,000 mg/day of mixed omega-3 and
omega-6.
- Soft foods high in flavonoids provide antioxidants to decrease pain
caused by free radical buildup in the joint.
- Avoid saturated fats, fried foods, and caffeine, all of which increase
inflammation. Avoid chewing gum.
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1
heaping tsp. herb/cup water steeped for 10 minutes (roots need 20
minutes).
- St. John's wort (Hypericum perforatum) may improve serotonin
levels affected in TMJ. Oil may be applied topically. Oral dose is 250 mg
tid.
- Cramp bark (Viburnum opulus) and lobelia (Lobelia
inflata) are antispasmodic. Rub 5 drops tincture of each herb into joint. Do
not apply to broken skin.
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Homeopathy |
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An experienced homeopath would consider an individual's constitutional type
to prescribe a more specific remedy and potency. Some of the most common acute
remedies are listed below. Acute dose is three to five pellets of 12X to 30C
every one to four hours until symptoms resolve.
- Causticum for burning pains that are better in rainy weather
and worse in dry weather
- Hypericum perforatum for sharp shooting pains, especially after
an injury or dental work
- Ignatia for tension in the jaw after a grief or
conflict
- Kalmia for face pain especially with other joint
pains/arthritis
- Magnesia phosphorica for muscle cramps that feel better with
heat and pressure
- Rhus toxicodendron for pains that feel better in the morning
and in dry weather, and worse after movement or in wet weather
- Ruta graveolens for pains from overuse or injury that are
better with rest
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Physical Medicine |
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Contrast hydrotherapy. Alternating hot and cold applications brings nutrients
to the site and diffuses metabolic waste to decrease inflammation, provide pain
relief, and enhance healing. Use hot packs and ice wrapped in a wash cloth and
apply to area. Alternate three minutes hot with one minute cold and repeat three
times. This is one set. Do two to five sets/day. |
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Acupuncture |
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May help decrease spasm and reduce frequency and intensity of
symptoms |
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Massage |
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Cranio-sacral and chiropractic manipulation may be useful to decrease muscle
spasm, provide pain relief, and prevent recurrence.
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Patient Monitoring |
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Ongoing assessment of conservative therapies is
appropriate. |
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Other
Considerations |
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Prevention |
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- Stress reduction
- Awareness and efforts to stop bruxism and
clenching
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Complications/Sequelae |
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- Prolonged teeth clenching or grinding, trauma, infection, or
connective tissue disease may cause severe malocclusion or intracapsular joint
derangement, which may result in degenerative joint disease or arthritis. The
diagnosis is confirmed by radiologic examination. Although rare, the
implications are serious and may require teeth regrinding or surgery. Patients
with severe grinding may benefit from nighttime use of a splint or bite
guard.
- Severe trismus—apply refrigerant spray (e.g.,
ethyl chloride), then standard therapies
- Arthritic conditions
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Prognosis |
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TMJ dysfunction is almost always self-limiting. Irreversible treatments, such
as teeth regrinding and surgery, are rarely called for and have a limited
efficacy. |
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Pregnancy |
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N/A |
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References |
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Challem J. TMJ pain may be aggravated by free radicals, relieved partly by
anti-oxidants. The Nutr Reporter. 1998.
Crider AB, Glaros AG. A meta-analysis of EMG biofeedback treatment of
temporomandibular disorders. J of Orofacial Pain. 1999;13(1):29-37.
Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
Md: Lippincott Williams & Wilkins, Inc.; 1999.
Ernberg M, Hedenberg-Magnusson B, et al. Pai, allodynia and serum serotonin
level in orofacial pain of muscular origin. J Orofacial Pain. 1999;
Winter 13(1):56-62.
Goroll A, ed. Primary Care Medicine. 3rd ed. Philadelphia, Pa:
Lippincott-Raven Publishers; 1995.
Jagger RG, Bates JF, Kopp S. Temporomandibular Joint Dysfunction.
Oxford, England: Wright; 1994.
Koopman WJ, ed. Arthritis and Allied Conditions. 13th ed. Baltimore,
Md: Williams & Wilkins, Inc.; 1997.
Marbach JJ. Temporomandibular Pain and Dysfunction Syndrome. Rheum Dis
Clin North Am. 1996;22(3).
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:111-114, 185-186, 187-189,
208-209, 237, 324-325, 329-330.
Roberts J, Hedges J, ed. Clinical Procedures in Emergency Medicine.
3rd ed. Philadelphia, Pa: W.B. Saunders; 1998.
Rosen P, ed. Emergency Medicine: Concepts and Clinical Management. 4th
ed. St. Louis, Mo: Mosby-Year Book; 1998.
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |