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.

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

• 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

• 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

• 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

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).

• 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

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.

• Often diagnosed by a dentist
• History and physical examination of the masticatory system

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.

• 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

• 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

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.

• 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.

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.

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

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.

May help decrease spasm and reduce frequency and intensity of symptoms

Cranio-sacral and chiropractic manipulation may be useful to decrease muscle spasm, provide pain relief, and prevent recurrence.

Ongoing assessment of conservative therapies is appropriate.

• Stress reduction
• Awareness and efforts to stop bruxism and clenching

• 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

TMJ dysfunction is almost always self-limiting. Irreversible treatments, such as teeth regrinding and surgery, are rarely called for and have a limited efficacy.

N/A

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.