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Temporomandibular Joint Syndrome

Kushagra Maini; Anterpreet Dua.
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Last Update: December 14, 2019.

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Introduction
The temporomandibular joint syndrome is also known as temporomandibular disorder
(TMD) is a common type of musculoskeletal disorder in the orofacial region involving
the masticatory muscles, temporomandibular joint (TMJ) and associated structures. The
typical features are pain in TMJ, restriction of mandibular movement, TMJ sound, and
facial deformities.
TMJ Anatomy
The temporomandibular joint (TMJ), also known as ginglymoarthrodial joint, is a bi-
arthrodial joint that is composed of the temporal bone's articular surface and the head of
the mandible, enclosed in a fibrous capsule. The joint is separated into two synovial
joint cavities by an articular disc. The anterior portion of the disc is attached to the joint
capsule, articular eminence, and the upper area of the lateral pterygoid. The posterior
portion relates to the mandibular fossa and the temporal bone, also referred to as the
retrodiscal tissue. The three major ligaments, temporomandibular, stylomandibular, and
sphenomandibular ligaments, stabilize the TMJ.
Arterial blood supply to the TMJ is primarily from the superficial temporal and
maxillary branches of the external carotid. Other contributing branches include the
anterior tympanic, deep auricular, and ascending pharyngeal arteries. The sensory nerve
supply to the TMJ is by the auriculotemporal and masseteric branches of the
mandibular nerve (V3), which is a branch of the trigeminal nerve.
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Etiology
TMD etiology is multifactorial. Various theories, such as mechanical
displacement, trauma, biomedical, osteoarthritis, muscle theory, neuromuscular,
psychophysiological, psychosocial theory, have been proposed to cause TMD.[1][2][3]
[2][1] Several factors, either alone or in combinations, are responsible for TMD.[4]
[5] Due to multifactorial etiology, the most common factors are: 
1. Predisposing factors -The factors that increase the risk of TMD or orofacial
pain. It further subdivides into systemic, psychologic, structural, and genetic
factors.
2. Initiating factors -The factors that cause the onset of disorder such as trauma,
overloading of joint structure such as parafunctional habits.
3. Perpetuating factors -The factors that interfere with healing or complicate
management such as mechanical, muscular stress, and metabolic problems.
The factors can influence each other or act together.
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Epidemiology
Epidemiological studies from around the world confirm a very high prevalence of TMD
dysfunction. Reports indicate that 39.2% have at least one symptom of TMD. The
incidence rate is 3.9% among adults and 4.6 % among adolescents. Symptoms of TMD
are common in all age groups. Older age groups demonstrate slightly more symptoms
than the young.  Women are affected more than men, observed as 2 to 1 in population-
based studies, and 4 to 1 in clinical settings. No gender differences have appeared in
children, but the ratio becomes 2 to 1 in young adults (female to male ratio).[6]
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Pathophysiology
Classification:
Farrar (1972), Block (1980), Welden. E. Bell (1986) AACD (1990), Edmond truelove,
SamuelDwork and Linda LeResche, Suvinen et al. (2005), Stegenga (2010), Machado
et al. (2012), Peck et al. ( 2014), Schiffman et al. ( 2014) proposed various systems of
classification of TMD [7]. The Schiffman classification published the diagnostic criteria
(DC)/TMD represents the evolution of widely accepted research diagnostic criteria of
TMD in 1992. It is a two-axis system physical axis and psychosocial diagnosis. The
physical system divides into the most common joint problems and muscle conditions.
The classification proposes a more standardized, reliable self-reporting questionnaire,
clinical examination systems, scores, and decision trees. It integrates biophysical
diagnosis to disability index, which measures the impact of pain on patient behavior.
The classification depends on clinical examination procedures; the assessment of
specific disorders is best through imaging procedures not included in the classification.
The most accepted classification that aids in the understanding of the pathophysiology
is Perk and Schiffman et al. (2014)[8] and Bell (1986).
Weldon Bell presented a classification that logically categorizes these disorders, and the
American Dental Association adopted it with few changes. The use of such a logical
classification system benefits diagnostic capability as well as communication within the
profession. All temporomandibular joint disorders divide into four broad categories
having similar characteristics as follows:
I. Masticatory Muscle Disorders:
The most common type of pain observed in patients is pain in the masticatory muscles
when swallowing, speaking, and chewing. Pain increases with palpation or with
manipulation of muscles. It is associated with restricted mandibular movements.
II.Temporomandibular Joint Disorders:
Temporomandibular joint disorders subdivide into three major categories:
1. Derangement of the condyle-disc complex:
The derangement of the condyle disc complex arises due to breakdown in the rotational
function of the disc. This condition can result from the lengthening of ligaments (discal
collateral and inferior retro-discal ligaments) or thinning of the posterior disc border.
The contributing factors can be micro or macro trauma. The derangements are of three
types:
     i. Disc displacements:
In the event of constant stretching of the inferior retro-discal lamina and the discal
collateral ligament, the discs get positioned anteriorly due to the function of the superior
lateral pterygoid muscle. The changes in disc and muscle position lead to a translator
shift of the condyle during the opening. The movement is associated with click or sound
in either or both during the opening and closing of the mandible.
     ii. Disc dislocation with reduction:
The disc displacement can either lead to partial or complete disarticulation of the disc
from discal space in condyle – disc assembly leading to disc dislocation. The
dislocation is reduced in situations when the patient can manipulate the mandible to
reposition the condyle to the disc position. The condition clinically presents with a
controlled range of jaw opening and jaw deviation in the process of opening the mouth.
The reduction of the disc creates loud pop during disc reposition. The interincisal
distance of disc reduction during opening is greater than when the disc is re dislocation
during the closure.
     iii. Disc dislocation without reduction:
The repositioning of the disc can become problematic due to the loss of elasticity in the
superior retro-discal lamina. This situation causes forward translation of the condyle
forcing the disc in front of the condyle. It presents as a locked jaw in closure, and a
normal opening is not achievable. Clinically it is represented as difficulty in maximum
opening. The mandibular opening is around 25 to 30 mm, deflects towards the involved
joint, and associated with pain. The bilateral manipulation technique of loading the joint
is painful due to the position of the condyle in the retro-discal tissues. 
    2. Structural incompatibility with articular surfaces:
The disorder results from changes in the smooth sliding surfaces of the TMJ. The
alteration causes friction, stickiness, and inhibits joint function. The structural
incompatibility classifies as a deviation in form, adhesions, subluxation, and
spontaneous dislocation
     i. Deviation in form:
The physiological, aging, or minor degenerative alterations in the condyle, disc, and
fossa can cause deviations and dysfunction, which significantly affects the mandibular
movements.
     ii. Adherences and adhesions:
An adherence represents a brief hold of the articular surfaces. Adhesion can happen
between the condyle- disc or amidst the disc or between the disc-fossa. Adhesions are
created by the development of fibrous connective tissue or due to loss of lubrication
between the structures. It characteristically demonstrates restriction in the normal
translation of the condyle movement with no pain. In chronic situations, the patient
senses an inability to get the teeth back to occlusion during the closure.
     iii. Subluxation and luxation (hypermobility):
It is a non-pathologic condition, repeatable clinical phenomena characterized by a
sudden forward movement of the condyle past the crest of the articular eminence during
the final stages of mouth opening. The steep, short posterior slope of the articular
eminences and the longer anterior slope, which is more superior to the crest, causes the
condyle to subluxate. The examiner can witness it by requesting the patient to open
wide, and this also creates a small void or depression behind the condyle.
    iv. Dislocations:
Dislocations are the result of hyperextension of the TMJ. It causes the fixing of the joint
in an open position during the opening of the mouth. Open-lock prevents the translation
of the mandible. The imaging displays the posterior position of the disc in relationship
to the condyle. The anterior teeth are usually separated, and the posterior teeth closed,
the patient shall find difficulty in closing the mouth, and pain is associated with it.  
     3. Inflammatory disorders of the TMJ:
The joint disease of inflammatory origin characteristically presents with deep
continuous pain that commonly gets accentuated on functional movement.  The
continuous pain can trigger secondary excitatory effects. It expressed as referred pain,
sensitivity to touch, protective contraction, or a combination of these problems.
Inflammatory joints also get classified according to the structures involved, such as
synovitis, capsulitis, retro-discitis, and arthritis.
     i. Synovitis/capsulitis:
Trauma or abuse can cause inflammation of the synovial tissues (synovitis) and the
capsular ligament (capsulitis). Clinically it is difficult to differentiate, and arthroscopy
is useful for diagnosis. It presents as continuous pain, tenderness on palpation, and
limited mandibular movement.
     ii. Retrodiscitis:
It is caused due to trauma or due to progressive disc displacement and dislocation. The
patient complains of pain, which increases with clenching. Limited jaw movement,
swelling of retro discal tissues, and acute malocclusion are associated with the disease.
    iii. Arthralgia
Pain originating in the joint that is affected by jaw movement, function, or para-
function and replication of this pain occurs with provocative testing of the TMJ.
    iv. Arthritis
Pain originating in the joint with clinical characteristics of inflammation or infection
over the affected joint that is edema, erythema, and/or increased temperature.
Associated symptoms can include dental occlusal changes (e.g., ipsilateral posterior
open bite if intraarticular with unilateral swelling or effusion). This disorder is also
known as synovitis or capsulitis, although these terms limit the sites of nociception.
TMD is a localized condition; there should be no history of systemic inflammatory
disease.
a) Osteoarthritis :
It is an inflammatory disorder that arises due to an increased overload of the joint. The
increased forces soften the articular surfaces and resorb the subarticular surface. The
progressive loading and the subsequent regeneration causes loss of subchondral layer,
bone erosion, and osteoarthritis. It is evidenced by pain in joints and increases with the
jaw movements and associated with disc dislocation or perforation.
b) Osteoarthrosis:
Arthrosis is the adaptive unaltered arthritic changes of the bone due to decreased bone
loading. It occurs after the overloading of the joint, mainly due to parafunctional
activity and often associated with disc dislocation.
c) Systemic arthritis
 Several types of arthritides can affect the TMJ, including traumatic arthritis, infectious
arthritis, and rheumatoid arthritis.
III. Chronic Mandibular Hypomobility:
It is a long term painless restriction of the mandible. Pain occurs only when using force
to attempt opening beyond limitations. The classification of the condition is according
to the cause, as ankylosis, muscle contracture, or coronoid process impedance.
IV. Growth Disorders:
TMDs resulting from growth disturbances may be the result of a variety of causes. The
growth disturbances may be in the bones or the muscles. Common growth disturbances
of the bones are agenesis (no growth), hypoplasia (insufficient growth), hyperplasia
(excessive growth), or neoplasia (uncontrolled, destructive growth). Common growth
disturbances of the muscles are hypotrophy (weakened muscle), hypertrophy (increased
size and strength of the muscle), and neoplasia (uncontrolled, destructive growth). It
results from deficiencies or alterations in growth that typically result from trauma.
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History and Physical

History and examination of TMD
The objective of eliciting history and examination is to recognize the clinical signs and
symptoms. The factors to be included in history are[9][10][11][12][13]:
1) Chief complaints that include:
 Location, onset, and characteristic of pain
 Aggravation and relieving factors
 Past treatments if any and their result
 Any other pain disorders.
2) Past medical and dental history 
3) General systematic assessment
4) Psychologic assessment
Physical examination findings of TMD include decreased range of motion, signs of
bruxism, abnormal mandibular movements, tenderness of muscles of mastication, neck,
and shoulder, pain with dynamic loading, and postural asymmetry. It is vital to perform
an oral and dental examination to look for signs of tooth wear and a neurology
examination to look for any cranial nerve abnormalities. A click, crepitus, or popping
sensation which may accompany joint opening or closing may be associated with
anterior disc displacement or osteoarthritis.[14] Careful palpation of masticatory
muscles and surrounding neck muscles may be associated with myalgia, trigger points,
myospasm, or referred pain syndrome.[15][16]
The following baseline records should normally be part of the workup for patients
suspected of having a TMJ disorder:
 Clinical examination
 Radiographic examination of teeth and TMJ
 Diagnostic casts
The initial and most helpful study in diagnosing TMD is plain or panoramic
radiography, which may reveal acute fractures, arthritis, or disc displacements. Further
imaging studies like computed tomography (CT) or magnetic resonance imaging (MRI)
are beneficial in severe, chronic, or suspected structural abnormalities of TMJ.[17]
[18] Additionally, newer techniques of nerve blocks, botulinum toxin injections,
arthrography, and mandibular motion data can prove to be of significant diagnostic
benefit.
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Evaluation
Signs and symptoms of TMD[19][20]:
1) Pain:
Pain from the TMJ and muscles of mastication is a common symptom. It can be
constant or periodic dull ache over the joint, the ear, and temporal fossa. It is more
observed during the mandibular movement or by palpation of the affected regions. The
pain can be myogenic caused due to mechanical trauma and muscle fatigue. Articular
pain arising due to inflammation of articular and periarticular tissues either by
overloading, trauma, or degenerative changes.
2). Joint Sounds:
The two common joint sounds observed are clicking and crepitations.
Clicking is a sound of the short event observed during the mandibular movement
caused by the uncoordinated movement of the condylar head and the articular disc.
Crepitations are compound sounds that are caused by the roughened, irregular articular
surfaces of the joint  and observed during mandibular movement
3). Limitation of Mandibular Movement:
The restrictions in movement of the mandible are observable either in all or in part of
opening, closure, protrusion, and lateral movement. It can be due to muscular
restriction, disc displacement, ligaments restriction.
4). Dislocation:
It is the displacement of the condyle from fossa, and the patient may be unable to close
the mouth. The patient can reduce the dislocation himself or report to the clinician for
reduction.
5). Dental Symptoms:
Tooth mobility, pulpitis, tooth wear are the commonest dental symptoms elicited in
TMD patients.
6). Otologic Symptoms:
TMJ pain in the auricular regions is more noticeable posteriorly. Tinnitus, itching in the
ear, and vertigo are other symptoms associated with auricular pain.
7). Recurrent Headaches:
Patients perceive the pain and tenderness of masticatory muscles along the temporal
region as headaches. Additionally, it can correlate with other headaches, such as
migraine pain.
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Treatment / Management
Treatment of Temporomandibular disorders[21][22][23][22][24][25][24]:
The identification of the disorder and management could be a challenging task.  It is
imperative to determine the disorder with adequate evidence before initiating the
treatment. The treatment plan decision can be from among the various options
available.
The first step in treating TMJ disorders is symptomatic care, which usually consists of
(a) a soft diet, (b) mild inflammatory agents, (c) moist heat packs alternating with ice,
and (d) voluntary disengagement of the teeth.
Further treatment modalities can group into definitive and supportive treatment.
1. Definitive treatment:
The definitive treatment identifies the disorder and treats the cause of the disorder. The
various treatment methods are
a) Occlusal therapy:
The modifications in dental occlusion are the primary treatment method of TMD. This
treatment focuses on altering the mandibular positioning. It identifies and removes
derangements in occlusion and contact interference. It classifies as either reversible or
irreversible occlusal therapy.
i) Reversible occlusal therapy:
CLinicians achieve this result with an occlusal splint that alters patient occlusion
briefly. The splints are made of acrylic, fixed over the teeth of one arch. The creation of
the opposing surface of the splint accounts for a new mandibular position. The
mandible returns to the original position on discontinuation of the splint. A stabilizing
splint is the commonest splint used. It aids in stabilizing the musculoskeletal position of
the mandible.
ii) Irreversible occlusal therapy:
The occlusal surfaces are altered forever in irreversible occlusal treatment. The tooth
interference or the default occlusal position of the teeth are identified and permanently
changed either by selective grinding of the tooth surface or by tooth restorations.
b) Emotional stress therapy:
Generally, TMD is associated with the emotional and psychological state. Muscle
activities become altered due to increased levels of emotional stress.
Stress management can be with patient behavioral therapy in the following ways:
i) Patient awareness:
The patient receives education regarding the relationship between stress and muscle
hyperactivity. This understanding aids in better behavioral management and improves
psychological health and the condition.
ii) Restrictive use:
In the majority of TMD situations, patients complain of pain in TMJ and restricted
mandibular movement. The clinician should instruct the patient to move the mandible
within a trouble-free range of motion, which promotes psychological health and pain
disorder.
iii) Voluntary avoidance:
The teeth contact can trigger the pain in patients. The patients must try to reduce tooth
contact time. Except during mastication, swallowing, and speaking, the clinician directs
patients to disengage the tooth to diminish the pain or discomfort coercively. A simple
exercise of lip puffing can voluntarily disengage teeth and enhance patient health.
iv) Relaxation therapy:
Relaxation is perceptive. Among the numerous relaxation techniques, patients are
encouraged to follow one that suits them to relax the muscles and promote
psychological health.  The stretch-relax procedure and progressive relaxation
techniques are commonly followed and effective among TMD patients.
2. Supportive Therapy:
Patient symptom management is through supportive therapy. The cause of TMD may
not be relieved with supportive treatment.
The following methods are the currently adopted approach for treating these patients:
 a) Pharmacologic therapy: Analgesics, Non-steroidal anti-inflammatory drugs
(NSAIDs), corticosteroids, anxiolytic agents, muscle relaxants, anti-depressants, local
anesthetics can be either administered locally or systematically to reduce the patient
symptoms. Typically, 10 to 14 days course of NSAIDs is the recommended course for
acute pain. Muscle relaxants are an optional adjunct to treat myospasm. If a patient
reports poor response in two to three weeks, tricyclic antidepressants (TCA) are another
option, especially if the pain is associated with bruxism.[26][27][28] 
Invasive strategies include intra-articular long-acting corticosteroid or hyaluronic acid
injections and trigger point botox injections. These interventions are recommended
once conservative therapies have failed or in severe acute exacerbations. Intra-articular
steroids are a recommended intervention for acute treatment of osteoarthritis of TMJ,
but multiple doses can lead to the destruction of articular cartilage.[29][30] There is
only limited evidence regarding the efficacy of hyaluronate injections in treating acute
exacerbations.[31] Botulinum toxin injections only for painful trigger points or chronic
bruxism, but a recent Cochrane study had inconclusive evidence for myofascial pain.
[32][33]
 b) Physical therapy: Physical therapy is commonly advocated as an adjuvant to
definitive treatment. Modalities used in physical therapy involve thermotherapy,
coolant therapy, ultrasound, phonophoresis, iontophoresis, electro galvanic stimulation
therapy, TENS, acupuncture, and cold laser. The commonly followed manual
techniques are soft tissue mobilization, joint mobilization, muscle conditioning,
resistance exercises, passive muscle stretching, assisted muscle stretching, and postural
training.
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Differential Diagnosis
Various other disorders can present as facial or ear pain or even headaches.  A thorough
history and physical exam with basic labs like blood counts, kidney and liver function
tests, and sedimentation rate help in localizing the lesion for most presentations of TMJ
pain.[15][34]
  Common causes of facial pain include trigeminal, glossopharyngeal, or post-
herpetic neuralgia, sinusitis, salivary gland disorders, and carotidynia.
  Common causes of headaches include migraines, cluster headaches, strokes,
and temporal arteritis.
  Common causes of ear pain or stuffiness are middle ear infections, injuries,
barotrauma, and Eustachian tube dysfunction. 
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Prognosis
Most patients with TMJ pain have a favorable response to treatment, whereas a small
number of patients develop refractory or persistent TMD. There are no known risk
factors associated with chronic TMD. Recent data published did correlate heightened
sympathetic tone with chronic TMJ pain.[35]
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Complications
There are no reported complications. 
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Consultations
Referral to an oral maxillofacial surgeon (OMFS) is the usual recommendation for:
1. Refractory TMD with no response to noninvasive or minimally invasive techniques
like intraarticular injections, trigger point injections or botulinum toxin injections
2. Structural or articular abnormalities
Imaging is diagnostic for most structural abnormalities. Surgical techniques include
arthroscopy, arthrocentesis, reconstructive jaw procedures, discectomy, and
condylotomy.[36][37]
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Deterrence and Patient Education

TMD conditions are among the most perplexing and intractable problems in clinical
dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often
accompanied by a restricted range of mandibular motion. Pain control is considered the
primary goal of TMD management. Once pain control is accomplished, improvement
and restoration of acceptable mandibular function are likely.
A thorough history and physical examination to arrive at the diagnosis are critical.
Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy,
dental remedies, and psychological assistance, can lead to effective management and
may curb the negative repercussions of TMD upon the quality of life and daily
functioning.
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Enhancing Healthcare Team Outcomes

TMD conditions are among the most perplexing and intractable problems in clinical
dentistry. Undoubtedly, the most salient and vexing TMD symptom is pain, often
accompanied by a restricted range of mandibular motion. Pain control is considered the
primary goal of TMD management. Once pain control is accomplished, improvement
and restoration of acceptable mandibular function are likely.
A thorough history and physical examination to arrive at the diagnosis are critical.
It is essential to communicate and collaborate between providers, as most patients with
TMD require a combined approach of both pharmacologic and non-pharmacologic
measures, which can help reduce suffering and alleviate the maximal symptoms of TMJ
disorder. The interprofessional team consists of primary care providers, dentists, oral
surgeons, physical therapists, nurses, and pharmacists. Nurses often provide education,
monitor patient response, and keep all team members updated on the patient's condition.
Nurses also can serve as a coordination point between different members of the
interprofessional healthcare team. Pharmacists provide instructions to patients about
medications, reviewing dosing and side effects, and check for any potential drug
interactions; reporting potential concerns to the team. [Level 5]
Utilizing a biopsychosocial strategy, consisting of physical therapies, pharmacotherapy,
dental remedies, and psychological assistance, can lead to effective management and
may curb the negative repercussions of TMD upon the quality of life and daily
functioning.
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Questions
To access free multiple choice questions on this topic, click here.
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