Vol. 2 No.

3 Summer 1987 Journal of Pain and Symptom Management 155

Special Article Special Series: Challenges in

Pain Management, Pan 1
Diagnosis and Treatment of
Temporomandibular Joint Disorders
Stephen D. Smith
Temporomandibular Center, Philadelphia College of Osteopathic Medicine, Philadelphia,
Pennsylvania

Introduction Other symptoms are sometimes reported by

Temporomandibular JOInt (TMJ) dysfunc-
tion has been called "the great impostor"
because its symptoms mimic so many other dis-
eases. The effects of a malpositioned TMJ and
mismatched, maloccluded jaws have been
extensively detailed in the dental and medical
literature. Ear pain, muscle-contraction, head-
ache, and other types of chronic craniofacial
pain have been attributed to disease of this
region.':"
The prevalence of disorders of the TMJ is
high. Epidemiological studies suggest that 20%
to 70% of the United States population have
various degrees of this dysfunction. Although
the symptoms and severity vary from patient to
patient, TMJ dysfunction is clearly a significant
and common problem.
Symptoms
The variety of symptoms related to TMJ dys-
function can be divided into primary and sec-
ondary categories. Primary symptoms include
muscle spasm; "earache" (pre- and post-auricu-
lar pain and internal auricular pain); and jaw
clicking, crepitation, pain, limitation of
motion, dislocation, and locking. Some
patients report tinnitus and hearing loss, brux-
ism, or dizziness. The area of muscle spasm and
pain includes internal and external pterygoids,
masseters, temporalis, sternocleidomastoids,
posterior cervicals, mylohyoids, and trapezius.!
Patients may also experience pain in individual
teeth.
Address reprint requests to: Stephen D. Smith, DMD,
FAGD, Temporomandibular Center, Philadelphia
College of Osteopathic Medicine, 4150 City Ave.,
Philadelphia, PA 19131
Acceptedfor publication: December 18, 1986
The publication costs for this special series are supported by educational grants from the following companies:
The Kendall Company, Boston, Massachusetts; The Purdue Frederick Company, Norwalk, Connecticut; and Roxane
Laboratories, Columbus, Ohio. The series editor is Steven D. Waldman, M.D.
patients with TMJ disorders. These symptoms
may suggest cervical pain, migraine, sinusitis,
difficulty swallowing, burning tongue, visual
dysfunction and motor incoordination, facial
neuralgia or simple fatigue.
With this number of potential symptoms,
diagnosis may be difficult. In many cases a
multidisciplinary approach is required, includ-
ing a thorough medical history, extensive den-
tal history, and a temporomandibular orthope-
dic detailed examination.
Initial Interview
A detailed evaluation of the craniofacial pain
patient is necessary. Patients are asked when
the pain first began, what exacerbates or
relieves it, and what they suspect is its cause.
Drawing the location of the trigger points and
main pain areas with a pain referral map may
be useful."
A standard medical history is essentiaL This
should include reference to past traumatic inju-
ries, such as motor vehicle accidents, which can
cause major joint displacement and intense
pain throughout the entire head, neck, and jaw
region,6.7
Patients are also questioned about the
degree of anxiety and depression associated
with their current pain state. Nutritional status
should be queried, including a review of the
patient's eating and drinking habits, and the
use of drugs, both prescription and over the
counter, should be assessed." A family history is
taken and the dental history is reviewed, with
the patient listing any past difficulties and the
current dental needs by priority.
156
Clinical Examination
To begin the clinical examination, the gen-
eral contour of the face should be evaluated
from a frontal and side view. The jaw-to-jaw
relationship and its height are critical in look-
ing at the patient with TMJ dysfunction. As the
overall facial appearance and contour is
assessed, the TMJ itself should be palpated for
obvious displacement and evidence of pain on
opening and closing. The use of a stethoscope
to monitor joint sounds is invaluable in assess-
ing the status of the temporomandibular joint.
Frictional rubbing sounds as well as frank pop'
ping and displacement should be noted in the
workup," The location and intensity of the click
or displacement should be charted. These
sounds can be magnified electronically and
analyzed on computer with a graphic display
readout.l?
The bite or occlusion of the teeth is charted.
In the ideal occlusion, there is full posterior
support with a normal overjet/overbite relation-
ship. The term overjet refers to the amount of
maxillary incisal protrusion compared to retru-
sion of the lower/mandibular incisors. The
term "overbite" means the depth of bite or the
collapse of the vertical dimension of the jaws.
The patient with a deep overbite and mandibu-
lar retrusion is very susceptible to TMJ disor-
ders. A normal or ideal bite provides a full
range of motion of the jaw without any frank
displacement.
The range of motion of the jaw is assessed on
opening and closing and on lateral move-
merits." The patient should be able to open
and close in a straight line without displace-
ment or pain and should open in the range of
42 to 55 millimeters. The patient should open
and close without deflection or jaw deviation.
From the teeth together position, the patient
should be able to move the jaw laterally each
way approximately 12 millimeters. He/she
should be able to protrude the jaw 10 millime-
ters, again without clicking or displacement.
Premature contacts of the teeth during these
functional ranges should be noted, as these
contacts can be harmful to the jaw musculature.
Charting of each individual tooth is done,
noting the fillings, active decay, periodontal
health, fractures, and wear and abrasion. Spe-
cific teeth may refer pain to other areas of the
face and neck.
Smith Journal of Pain and Symptom Management
Palpation is done to the intraoral as well as
the extraoral masticatory musculature and cer-
vical region.I2 The muscles in the posterior
region of the mouth, base of the tongue, as well
as under the throat should be assessed for pain-
ful contraction. Areas outside the mouth, most
notably the masseter and temporalis muscles of
the jaw, should also be palpated bilaterally. The
TMJ should also be pal pated to test for pain in
front of the ear canal, around the outer capsule
of the joint. The joint should be palpated on
opening and closing with the little finger
inserted in the ear canal to test for tenderness
in the posterior region of the disk. This area,
the retrodiscal tissue, can refer pain directly
into the ear. The back of the TMJ is the front
wall of the ear canal, so the ear canal should be
examined through an otoscope to screen for
organic cause of ear pain.
Palpation should extend to the neck areas
and base of the skull, as many headache pat-
terns are referred from the neck musculature.P
The cervical muscles and paravertebral struc-
tures down through the shoulder should be
palpated, since they may be the source of pain
referred upward to the head, TMJ, and face. 14
The range of motion and restriction or limi-
tations of the neck should also be noted.P The
movement of the head to the left and right
should be approximately 85 degrees on turning
and 45 degrees on side bending without pro·
ducing pain. The head should be able to bend
or flex forward 65 to 70 degrees and bend or
extend backward 40 degrees.
Changes in anatomy due to loss of teeth, col-
lapse of dental arch, wear and tear of the TMJ,
trauma, fibrosis, scarring, or forward head pos·
ture may all precipitate problems elsewhere.
Pain may occur, and the normal range of
motion may be limited. The neck muscles serve
as accessory jaw opening levers and tilt the
head backward as the jaw is brought downward.
Restrictions in the neck vertebrae cause extra
jaw musculature overloading. When the TMJ is
significantly displaced, the neck musculature
must overwork thereby causing extra fatigue
and potentiating muscle spasm.
Diagnostic Studies
Radiographs of the head and neck may be
necessary to properly evaluate changes in func-
tion. The curvature of the cervical spine can be
Vol. 2 No. J Summer 1987
assessed, and any evident bony pathology, nar-
rowing of the disc spaces, osteophytes or joint
degeneration can be seen. The contour of the
soft tissue profile of the face is matched to the
alignment of the maxilla and mandible, and
the individual tooth angulations and positions
can be evaluated. A number of cephalometric
tracing patterns may be done to assess the jaw-
to-jaw as well as tooth-to-tooth relationship.
Transcranial TMJ radiographs are taken to
identify cysts, flattening of the bone surface,
fractures, or other irregularities" (Fig 1). The
joint space is also analyzed and typical jaw posi-
tions taken, such as teeth together, relaxed or
Fig 1. Arthritic degenerative joint disease is seen i~
the condyle, as the head is worn flat, and the earn-
lage has become roughened and abraded. A fric-
tional rubbing sound or "crepitus" is usually heard
at this stage. A bony point or osteophyte is seen on
the lower front margin of the condyle.
rest position, wax bite repositioning, splint
position, andlor full openingP These views
provide clues to the integrity of the radiolucent
disc which lies in between the articular erni-
nence of the temporal bone and the condyle.
The joint itself has an upper joint space and a
lower joint space compartment with synovial
fluid lubrication and a membrane lining. The
disc may become dislodged or displaced
through trauma. It also may break down over
time from a malocclusion or with a significant
overloading and excessive stress bearing within
the joint. With posterior displacement of the
condyle, the disc may tear loose and become
locked anteriorly. With direct blows or with
whiplash-type injuries, the jaw may become dis-
placed due to excessive opening, with tearing
of the posterior ligaments and shifting of the
disc. III•19 Degenerative joint disease occurs with
flattening and erosion of the articular surface
TA1J Disorders 157
and a marked narrowing of the joint spaces.
The use of computerized axial tomography
(CAT) can provide added detail of the TMJ
structures.s" Sections up to two millimeters
apart can be tomographically analyzed for
cystic degeneration, changes in bony density,
neoplasm and fracture. The location of the soft
tissue of the disc can also be seen and measure-
ments can be taken of the joint spatial rela-
tionships.
Joint arthrography is utilized for visualiza-
tion of the joint space compartments." Hernia.
tions and frank tears, as well as joint adhesions
can be assessed through this approach. A con.
trast agent is usually injected into the inferior
joint space. Fluid leakage into the superior
joint space indicates tears and herniation.
Excellent visualization of the dynamic range of
motion of the jaw and disc assembly can be
seen, and the opening and closing phases of
jaw/joint movement can be recorded.F' The
degree of clicking and locking and stages of
reduction and recapture of the disc can also be
noted.i"
Magnetic resonance imaging (MRI) is able to
demonstrate clearly soft tissue detail. The loca-
tion and degree of displacement of the TMJ
disc is also apparent by the technique.s" The
tension levels in the area of pain and con.
traction may be excessive and need objective
monitoring.
The use of a sophisticated electronic instru-
mentation system, called the mandibular kine.
siograph, has brought new diagnostic data to
the temporomandibular center. The use of an
oscilloscopic tracing of the jaw range of motion
can be useful in assessing the degree of jaw
dysfunction. Its tracing can be photograph]-
cally preserved for future reference. It can also
record the velocity of jaw opening and closing
and indicate a slowed traumatic and irregular
pattern of movement as well as measure the
level of displacement on opening and closing. 25
Finally, the use of a myomonitor can be a
helpful diagnostic, as well as treatment, tool in
assessi ng the degree of closure of the jaws. Elec-
tromyography (EMG) is utilized particularly on
the masseter and temporalis muscles; it mea.
sures electrical activity which may reflect ten.
sion levels. The left versus right side is analyzed
in the mandibular rest position and with the
jaws closed together.'" Excessive dominance of
one muscle group over the other can be quanti-
158
fied. With a computerized graph and chart, the
areas of initial tooth contact can be visualized
as full bite closure occurs. The level of base-line
muscle activity can be compared to later levels,
particularly after various physical therapy
modalities have been used and as the patient
progresses. Muscle activity can also be moni-
tored during biofeedback.
Impressions ofthe maxilla and mandible can
be taken and plaster casts made. These serve as
models which may be mounted on a dental
articulator to provide a functional analysis of
the occlusion." Repositioning of the mandible
can be done with various thicknesses of sof
tened wax (trial wax bites) as the dentist designs
and records a therapeutic jaw position. The
wax insertion relates the lower jaw position to
the maxillary teeth and simultaneously changes
the position of the TMj structures. The wax bite
may then be placed in the patient's mouth to
verify the repositioning and any joint clicking
or displacement can be re-analyzed with the
new position. Often, jaw clicks and other asso-
ciated noises are reduced or may even disap·
pear from the wax bite repositioning. The first
device made from the models may be a soft
vinyl nightguard. After wearing the nightguard
for one week some benefits may occur, either in
the form of reduced facial pain, improved joint
comfort, or an improved range of motion in
the neck and jaw. The nightguard then serves as
both a diagnostic and treatment tool.
Diagnosis
The information gathered by clinical exami-
nation and imaging procedures is used to
develop a differential diagnosis. Distinction
must first be made between TMjJcranioman·
dibular disorders of organic origin and non-
organic or functional disturbances. Organic
disorders comprise articular disturbances and
non-articular disturbances.i" Articular distur-
bances include derangements of the disc, con-
dylar displacement, inflammatory conditions
(synovitis; capsulitis; contusion; rupture; and
arthritides, such as osteoarthritis, rheumatoid
arthritis, gout, and infectious arthritis). Also
included are ankylosis, fractures, neoplasia,
and developmental abnormalities such as
hyper- and hypoplasias.
Non-articular disturbances include such con-
ditions as muscle contracture (shortening) and
trismus. Dental occlusion conditions also can
Smith Journal of Pain and Symptom Management
be categorized as "non-articular disturbances;"
lack of posterior occlusal support is in this cate-
gory. Related organic conditions include cer-
vical sprains, trauma, and neurological dis-
orders.
Disorders of functional origin include
myofascial pain syndrome, bruxism, occlusal
neurosis, atypical facial pain, conversion hys-
teria and adjustment reaction with depres-
sion. 29 In the patient with complex pain pat-
terns, the diagnosis is often a multiple one.
Initial Treatment
After a diagnosis is made and other treatable
causes of craniofacial pain ruled out, a trial of a
therapeutic nightguard may be done, as de-
scribed above.
The use of physiotherapies may be most
helpful in relieving pain and improving func-
tion. Electrogalvanic stimulation is most often
used for the various head, neck and jaw mus-
cles. 3o Hydrocollator moist heat packs are often
used and may improve blood flow locally and
soften the local tissue sites. Alternatively cold
packs can be used to reduce pain and swelling.
Ultrasound may be beneficial and can improve
the mobility of the joints as well as reduce local-
ized muscle pain. Some practitioners ion-
tophoretically deliver medication locally'" The
use of transcutaneous electrical nerve stimula-
tion (TENS) may provide pain relief at numer-
ous locations throughout the head/neck and
back area.
Manipulation can involve the ternporoman-
dibularjoint,jaw muscles, and neck complex. It
may be used to attempt to bring the head of the
condyle into a proper relationship anatorni-
cally with the disc tissue ("recapture"). It may be
used also to stretch the muscles through
myofascial release techniques.V This can be
coordinated with vapocoolant spray and
stretch procedures. Cervical traction may also
be helpful in relieving neck pain. 33 A mouth
guard should be worn to prevent any excess
pressure to the TMj during the cervical
traction.
Orthopedic repositioning appliances or
splints are one of the most basic parts of TMj
therapy" (Fig 2). Splints are usually removable
and are used to fit over the upper or lower
arches providing a new biting surface for the
jaws, thereby freeing the TMj and regaining
collapsed disc space.V' The position and fit of
Vol. 2 No.3 Summer /987
Fig 2. The use of a specially processed splint or
mandibular orthopedic repositioning appliance
helps stabilize thejaw(joint position. The splint fits
over the plaster model of the mandibular teeth (or
maxillary), providing functional anatomic chewing
surfaces. It is adjusted over a period of months and
may ultimately be utilized as a "nightguard,"
depending upon the patient's progress.
the splint on the teeth must be correlated to the
X·rays to help verify normalization of the joint
anatomy.
There are a number of different types of bite
appliances or splints. 36 .:l 7 A maxillary anterior
bite plate is often used to separate the upper
and lower posterior teeth while allowing incisal
contact, causing relaxation of the masticatory
muscles. Often an inclined plane or lingual
ramp is built into the incisal portion to bring
the lower jaw forward and to allow the disc to
heal. A full arch maxillary or mandibular splint
provides contact of the complete dentition in
all ranges of motion. Such an appliance can be
used to chew food and can be worn all the time
during the initial phases of therapy. A pivotal
splint is an appliance with contact primarily at
the area of the first molars. It us used to "pivot"
the jaw forward and decompress the TMJ. A
modified Sved maxillary appliance includes
contact in the incisal region as well as the last
molar region.
Patients with TMJ dysfunction may have
many concurrent pains of musculoskeletal ori-
gin and the use of osteopathic manipulation to
other areas of the body may be helpful in
restoring the patient to an improved sense of
well being. 3H•39 Trigger point injections, as well
as intraarticular injections with corticosteriods
and local anesthetics may provide additional
relief in selected parients.i''
The patient with a complex medical history
llIay need consultation with other specialists.
Other diagnostic tests may need to be coordi-
TM) Disorders /59
nated such as the use of CAT scans, arthro-
grams, neurological testing, audiometric
studies, and other dental or medical referrals.
Psychological therapies may be essential in
approaching and treating the pain patient."
Psychological disturbances may be a conse-
quence of the T~ syndrome or may represent
a. pre-existing personality disorder which pre·
disposes to the TMJ disorder.V In either case,
initial treatment for the practitioner should be
d~rected toward alleviating pain; in most TMJ
disorders, the somatogenic component as-
sumes predominance.f'' The concurrent inte-
gration of psychological treatments may in.
volve relaxation techniques, biofeedback, and
hypnotherapy.
Lang- Term Considerations
Those patients who can make the transition
from the use of the repositioning appliance or
splint into night-time use only may not need
long-term rehabilitation.v'<" Other patients
may exhibit immediate changes from the
removal of the splint, such as recurrence of
he~dache or facial pain, or new joint clicking.
Patients who cannot make the transition into
night-time use of the splint or night guard will
require further treatment for stabilization.t''
This. usually involves orthodontics, prostho-
dontics, or a combination of both. Certain
patients may also need surgical referral.
Once the splint has been discarded or used
as a nightguard only, the final adjustment of
the occlusion can be done by dental equilibra-
tion. Various marking papers or waxes can be
used to determine premature tooth contacts."?
These contacts may be microscopically shaved
(111000 of an inch increments) and the tooth
surfaces appropriately recontoured to improve
the way the teeth interdigitate and allow more
ideal function of the jaw on side to side chew.
i~g. Refin~ment of the bite by dental equilibra.
non requires highly skilled techniques and
smal.1 incremental changes from occlusal recon-
tounng can be immediately noticed by the
patients. .
The use of a long-term removable overlay
prosthesis may resolve those cases where the
splin~ needs replacement. The overlay prosthe-
SIS (Fig 3) looks like removable caps which are
connected and fit over the teeth. The transi-
tional splint usually serves as the template for
160
Fig 3. Once the transitional repositioning splint
appliance has been proven effective, a long· term
overlay prosthesis, such as this, may be designed.
This prosthesis is particularly appropriate if day-
time splint use is repeatedly necessary beyond use
as a "nighrguard"
the proper jaw-to-jaw position and dictates the
final overlay prosthesis design.
There are many orthodontic techniques
which can be utilized to finalize the bite once
the jaw-to-jaw relationship has been estab-
lished. A number of orthopedic removable
appliances can be utilized to expand the arch,
encourage the vertical eruption of the teeth,
and move individual teeth. 48 Fixed orthodontic
brackets may be directly bonded to the teeth
and various kinds of arch wires can be incorpo-
rated for final positioning of the teeth. 49 Verti-
cal rubber elastics can be utilized also to help
maintain the vertical position of the occlusion
and prevent relapse. Night-time retainers
should be considered once the arch is brought
into final position.
The use of fixed crown and bridge tech-
niques is a major consideration in rehabilitat-
ing the dental arches, particularly if the patient
has missing teeth which have not been
replaced.P" Some cases require a combination
of orthodontic tooth movement and crown and
bridge stabilization. Patients with partial and
full dentures can also be restored, utilizing
their existing dentures for the transitional
period. Prosthodontic relinings and laboratory
resetting of the denture teeth can be done in
order to help establish a healthy jaw-to-jaw rela-
tionship and a stable TMJ. New dentures may
need to be made after the transitional period
for long- term stabilization.
Surgery is needed infrequently to correct jaw
deformities (orthognathic surgery). The TMJ
itself may require surgery if the conservative
treatment has not been successful in alleviating
Smith Journal of Pain and Symptom Management
pain and/or the disc displacement. 51-53
Summary
The individual presenting with craniofacial
pain and TMJ disorders may present a difficult
symptom complex. Treatment can be compli-
cated and requires other specialists and a team
approach to patient care. A transitional period
of six months to one year may be necessary to
incorporate various physiotherapies, splint
modalities, and a range of other treatments;
this will depend upon the established diagnosis
and severity of the case. After a transitional
period, the patient should be more comfort·
able, have improved jaw function, and experi-
ence a reduction in head pain. Long-term stabi-
lization may be necessary by orthodontics,
prosthodontics, or a combination of dental
approaches.
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