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TMJ Disorders

Symptoms

Common symptoms include:

 Jaw and face pain.


 Jaw joint noise: such as clicking, crunching, grating or popping.
 Earache.
 Headache.
 Limited mouth opening
 Jaw locking.
 Pain radiating along the cheek bone or down the neck.
o Most jaw joint problems are made worse by chewing and at times of stress

Causes

What causes it?

 A knock to face or jaw


 Unexpected wide mouth opening - as in very wide yawn
 Biting down on something hard
 Tooth grinding (bruxism) and tooth clenching, often at night.
 Stress
 Nail biting
 Uneven bite or altered chewing pattern to avoid a sore tooth
 Association with other chronic pain conditions
o Chronic fatigue syndrome, fibromyalgia, migraines, IBS
o As sufferers mat have increased generalised pain sensitivity (central
sensitisation)
 Sometimes no obvious cause can be found but symptoms may be associated with
other stress related disorders such as tension, headaches, low back pain and
abdominal pain

What causes the pain?

 Muscles – can tighten and cause limited opening


 Cartilage disc – when it moves out of its normal position
o This can cause locking
 Headache
Prevalence

Age Prevalence
12-19 4.2%
18-24 2.5%
25-34 3.7%
34-44 4.5%
45+ 2-7%
*Females are more likely to be effected*

Prognosis

Number of episodes Chance


Single 12%
Recurrent 65%
Persistent 19%

 40% of cases resolve spontaneously


 50-90% of cases improve with conservative treatment

Classification

Masticatory muscle disorder (myalgia)

 Pain when the muscles are palpated


 Pain when mouth is open, unassisted to maximum
 Pain around Ear/ temporal region
 Pain is usually unilateral

TMJ (Disc displacement with reduction)

 Reproducible joint clicking


 Mandible deviates to the effected side – coincides with click
 Pain occurs when the mouth is forced open
 May have occasional closed lock

TMJ (Disc displacement without reduction)

 Persistent limited mouth opening and lateral movement


 Deviation to effected side on opening
 Locking may occur after a period of clicking
 Pain if the mouth is forced to open

Degenerative disorder

 Crepitus – caused by articular surface disruption with jaw movement – usually not
painful
 Pain from TMJ occurs on jaw movement and there is a point of tenderness
 Restricted jaw movement, deviation

Subluxation

 History of locking with self-manipulation to close


 Patient has hypermobility

Arthralgia

 Pain produced by palpation or any jaw movements


 can be caused by arthritis

Headache related TMD

 Headache in temporalis
o Reproducible via palpation

Management

NICE Guidelines

Steps in primary care:

 Check for Life threatening condition that presents as a TMJ disorder


o Use the Red flag assessment

 Immediately refer to oral med/ max fax if there is:


o A History of trauma or fracture to the TMJ
o Limited mouth opening
 This suggests a disc displacement (without reduction)

 With all Patients encourage self-management


o Reassure that TMJ disorders are usually none progressive and that
symptoms will usually improve (but fluctuate)
o If there is acute pain
 Eat a soft diet
 Rest the jaw
o Avoid parafunctional activities
 i.e. Yawning, clenching/ grinding, nail biting
o Short term analgesia
 Paracetamol
 NSAIDS
o Other pain measures
 Cold/warm compress
 Massaging
o Identify sources of stress
 Relaxation techniques
 Realistic targets
 Pacing
 Social support
 Screen for
 Generalised anxiety
o Give Insomnia guidance
 “sleep hygiene”
 Provide sources of information, most importantly
o NHS choicses – TMJ disorder information leaflet
o British assoc. oral surgeons – TMJ leaflet
o Orofacial pain project – leaflet
o European academy of craniomandibular disorders – leaflet

 Consider a therapeutic approach


o Adults, acute and severe pain – Diazodiazepine
 2mg diazepam up to 3x a day (max of 2 weeks)
o Chronic pain
 Prescribe a neuropathic analgesic
 Amitriptyline (off-label) or (gabapentin (off label)

 Further referrals are needed to:


o Dentist
 Poor oral health
 Malocclusion
 Dental pathology
 Occlusal splint
 To be worn at night (for bruxism)
o Psychological services
 For CBT, if there is marked phycological distress
o Physiotherapy
 Passive jaw stretches
 Posture training
 Massage
 Arrange referral to oral medicine; oral and maxillofacial surgery; ear, nose,
and throat (ENT) surgery; neurology; or a multidisciplinary pain clinic for
specialist investigations and management, depending on clinical judgement,
if a person has:
o Chronic TMD lasting 3+ months
 Notes as chronic pain
o Persistent worsening of symptoms
o Uncertain diagnosis
o Psychological distress with symptoms
o Persistence or chronic widespread pain.