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Temporomandibular Disorders ( TMD )

TMDs-regarded as a group of heterogeneous musculoskeletal & neuromuscular pain conditions , they can be best described as ” Temporomandibular disorders ( TMD ) is an umbrella term for pain and dysfunction involving the masticatory muscles and temporomandibular joints ( TMJs )- Thomas List et al Cephalalgia 2017


Literature quotes a wide variability in the prevalence of TMD Most papers report a lower number of 5 % , Durham et al say that TMD may affect upto a 3rd of the general population reportedly ranging from 5 % to 50 % TMD is more common in women ( and they seek more help ) Peak incidence is widely quoted to between 20-40 yrs Incidence decreases with age It is quoted as 2nd or 3rd most common MSK pain ( after LBP & neck pain ) TMD is the 2nd most common cause of pain in mouth and face after odontogenic pain & is the most common cause of chronic pain in the orofacial region It was James Bray Costen who in 1930s incorrectly thought that the cause of TMJ are due to changes in occlusion – since then the terminology has been revised several times and now umbrella term TMD is widely accepted Only about 5 % of patients with TMD seek treatment


Etiology- Etiology is poorly understood but is considered complex and multifactorial It possibly is a combination of psychological , physiological , structural , postural and genetic factors which alter the functional balance between the fundamental elements of the stomatognathic system : dental occlusion , jaw muscle and TMJ The author finds the explanation by Andrea Maria Chisnoiu et al ( Clujul Medical 2015 ) as most comprehensive which groups the numerous factors into 3 categories.


Predisposing factors – these increase the risk of developing TMD these are pathophysiological , psychological or structural processes that alter the masticatory system and lead to an ^ ed risk of developing TMD


Initiating factors – these are responsible for the onset of the disease mainly related to trauma or adverse loading of the masticatory system.


Perpetuating factors – these may include
- behavioural factors ( grinding , clenching & abnormal head posture ) social factors ( affect perception and influence of learned response to pain ) emotional factors ( depression & anxiety ) cognitive factors.


In some case one factor alone may serve one or all of the above roles Etiological factors can be occlusal abnormalities , orthodontic treatment , bruxism and orthopaedic instability , macrotrauma and microtrauma , jt laxity and exogenous estrogen.


Possible risk factors – Risk factors are not clearly defined but certain well studied associations 
have been observed Considerable evidence exists to say that psychological and psychosocial factors are of significant importance in the understanding of TMD
- behavioural stress may cause or aggravate TMD
- higher stress , anxiety and depression scores are associated with higher level of TMD severity score Parafunctions – impaired or altered functions of TMJ for e.g excessive gum chewing , teeth clenching and bruxism Occlusal factors- widely studies ( initially by Costen ) and thought to have a possibly role in both susceptibility and onset or perpetuation of TMD Joint hyperlaxity and hypermobility – link is not well established Estrogen -considered to contribute to ligament laxity & women on hormonal treatment are thought to suffer with more painful symptoms ( estrogen receptor polymorphism theory ) Microtrauma – can be initiating / predisposing factor for e.g whiplash injury.


Diagnosing TMD can be a challenging task- consider the diagnosis if the presentation is with. The location of the pain is around the TMJs and the muscles of mastication often worsened by function You can elicit muscle and joint tenderness on palpation Joint sounds – clicking ( widely quoted but beware that AFP article mentions that adventious sounds for e.g, clicking , popping , grating, crepitus also can happen in 50 % of asymptomatic patients ) Restricted mandibular movements or limitation/ incoordination Associated disorders – headache being the most common usually restricted to temporal region Earache.


Ask when did the pain start , character , radiation , intensity Any event / intervention that the patient feels may have triggered the pain Activities which make the pain worse for e.g chewing , kissing , yawning How does the pain relate to other features as joint noise and restricted mandibular movement Consider asking questions which cover the points covered in the box on etiology & risk factors Consider some degree of psychosocial assessment Observe / enquire about any parafunctional habits for e.g teeth clenching and grinding during sleep or when awake ( bruxism ) , nail biting.


The following points in the examination may support a diagnosis of TMD- this should include extra-oral and intra-oral examination of the structures of head and neck
 palpate the TMJ – note ROM & any noises abnormal mandibular movement decreased range of motion signs of bruxism palpate the muscles of mastication – note tenderness / hypertrophy palpate for tenderness – neck and shoulder note any lymphadenopathy look for any asymmetry oral examination for tooth wear cranial nerve abnormalities in people over 50 consider r/o temporal arteritis.


Diagnosis is clinical based on history and examination – Consider using a self rating questionnaire for e.g the Research Diagnostic Criteria for TMD ( RDC / TMD ) find that under links
 You may consider asking for a dental opinion from a general dental practitioner. A score of 3 or more is suggestive of positive screening for TMDs.


Diagnosis – Diagnosis of TMD is based on history and physical examination Pain less than 3 months is considered acute and > 3 months is chronic Consider other diagnosis and red flags (see below ) Common differentials to exclude are
- dental caries or abscess
- oral lesions like HSP , oral ulceration , lichen planus
- salivary gland disorders
- maxillary sinusitis
- trauma / dislocation
- neuralgias ( trigeminal , glossopharyngeal )
- giant cell arteritis A plain or panoramic radiography ( high level orthopantograms and transcranial projections ) are adequate first line imaging tests to visualise any gross pathological , degenerative or traumatic changes in the bony component of the TMJ complex Classification – several system exist and in general TMDs can be divided into intra-articular and extra-articular


Red flags – H/O malignancy Lymphadenopathy Persistent or unexplained neck lump Headache symptoms which may indicate a secondary headache as opposed to primary headache or sudden onset thunderclap headache Previous headache history & progression . very sudden increase in pain to this level or headache precipitated by Valsalva , postural aggravation , papilloedema Trismus ( which may prevent full examination ) Erythroplakia , erythroleukoplakia , leukoplakia or frank ulceration of oral mucosa Cranial nerve abnormalities Neurological dysfunction ( particularly of cranial nerves V , VII and VIII ) Systemic symptoms as unexplained fever and weight loss H/O head and neck malignancy Recurrent nose bleeds , purulent nasal discharge or loss of smell , persistent nasal obstruction Presentation after age 50 with signs and symptoms suggestive of GCA Facial asymmetry or mass ( for e.g periauricular mass ) Functional deficits as hearing loss Bite of teeth changes.


Dental conditions – For e.g caries or abscess , periodontal disease , cracked tooth , dry socket


For e.g parotitis , salivary gland stones (sialolithiasis ) sialadenitis , sinusitis ( maxillary )


Headaches – For e.g migraine , Tension-type headache , GCA , CVA , cluster headache and other trigeminal autonomic cephalgias , post-traumatic headache , medication overuse headache.

Neuralgias – For e.g trigeminal neuralgia , post herpetic neuralgia , glossopharyngeal neuralgia , peripheral neuritis , post-traumatic and post surgical neuralgia.


Treatment – Divided into non-invasive , minimally invasive and invasive treatments Reversible conservative treatment is the 1st line for all TMDs Treatment options are not extensive and can some time fail to meet the need of a relatively younger population Aim is to reduce or eliminate pain or joint noises or both and to restore normal mandibular function No single approach for treating TMD patients – pl see discussion below to see some common approaches.


Education – explain cause and nature of the disease reassure that this is a benign often self limiting / non progressive condition advice about self care ( see under links ) education should be the starting point for all patients with suspected TMD


Self management – Durham et al observe that this forms the basis of all reversible non-invasive management & involves reassurance , counseling with simple strategies of self help this can involve simple generic advice about hygeine , caffeine consumption & avoidance of parafunctional activities like daytime clenching , nail biting or excessive gum chewing support organisations and written guidance ( find under links ) ensure patient understanding , participation in management and the fact that TMDs are fluctuating conditions and exacerbations may happen.


Medications – no single drug is effective for all cases of TMD several groups of medications can be considered for e.g NSAIDs , opiates , muscle relaxants , tranquilizers and anti-depressants but the evidence base is limited to decide which mediation to use for chronic TMD in acute phase NSAIDs can be to relieve pain when an inflammatory component is suspected in acute phase of myogenous TMD – with myofascial pain & limited mouth opening Benzodiazepines may be considered for a short spell ( < 1 week ) tricyclic ADs in low doses can be useful for people who grind their teeth as it reduces muscle tension SSRIs have shown benefit in some studies gabapentin and pregabalin have also been used widely in TMD but their effect has not yet been proven in any clinical trial corticosteroids – have been used in moderate to severe TMD because of their anti-inflammatory properties & can be use topically , oral or within the joint botulinum toxin– has been studied in various RCTS with equivocal results


Occlusal therapy most common treatment offered by dentists for TMD involves using an appliance for e.g bite raising appliance , occlusal splint or a bite guard can alleviate symptoms but how it benefits has not been well understood


Others – behavioural therapies for e.g CBT psychotherapy physiotherapy and acupuncture orthodontics and occlusal equilibration.


Surgery -about 5 % of people with TMD require surgery procedures used can be TMJ arthrocentesis and arthroscopy to more complex open joint surgical procedures called arthrotomy


Information from Oxford Radcliffe Hospitals 6 page printable leaflet

Royal Surrey County Hospital has a 12-page useful leaflet on physiotherapy management of TMJ pain

National Institute of Dental and Craniofacial Research on TMJ with further reading links

Academy of General Dentistry on TMJ

British Association of Oral and Maxillofacial Surgeons on jaw joint problems



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