Temporomandibular joint pain dysfunction syndrome

This is the most common problem in and around the temporomandibular joint (TMJ). It is essentially pain in the pre-auricular area  and muscles of mastication with trismus, with or without evidence of internal derangement of the meniscus.


Epidemiology

Predominantly affects people aged between 20—40 years old. Equal frequency between genders, but five times as many females seek treatment. Affects around 40% of the population at some time in their life.

 

Aetiology

Idiopathic.  It is like to be associated with one of the following : occlusal abnormalities, lack of posterior support, parafunctional clenching habits, nocturnal bruxism, anxiety and depression.  (50-70% of patients have experiences stressful life events in the 6 months before onset.) Occasionally the patient may relate the onset of pain to an acute incident of local trauma while eating or yawning.

 

Symptoms

  • Unilateral or bilateral constant dull pain within the TMJ and/ or surrounding muscles
  • Pain on chewing, yawning or talking
  • If bilateral, one side usually worse
  • Trismus, limited jaw movements
  • Occasionally the TMJ may lock open or closed
  • Sounds—clicking, crunching or grating (crepitus) are often described
  • Headaches, facial pain and neck related aches
  • Cyclic pain which usually resolves, but may recur

 

Signs

  • Joint clicking—generated by displacement of the articular disc from head of condyle and then ‘popping’ back into correct position
  • Pain may be elicited on palpation of the TMJ and masticatory muscles. The muscles may be hypertrophic due to parafunction
  • Mandibular movement may be limited and deviation may occur on the opening or closing cycle
  • Parafunction habits in up to 50% of cases
  • Bruxism can be suggested by scalloping of the lateral borders of the tongue, ridging of the buccal mucosa, tooth wear, restoration wear, fracture, dentine exposure and sensitivity

 

Investigations

Organic causes of pain or limited movement should be ruled out by investigation.  Radiography is not recommended for diagnosis unless there is a history of trauma, significant limitation of movement, sensory or motor alteration, or a possibility of organic joint or other disease.  Trigeminal neuralgia can be occasionally triggered by movement of the jaw and should be suspected in older patients, particularly where pain is severe and paroxysmal.

 

Management

  • Most cases are self-limiting, therefore treatment should be conservative and reversible.
  • Patient information is an important aspect - Reassure and Explain
  • Habit management – Rest, avoidance of trauma
  • Occlusal appliances (full coverage hard POC, nocte wear)
  • Analgesia (NSAID’s), heat and massage, TENS
  • Remedial jaw exercises to aid faulty neuromuscular control
  • Muscle relaxants (Clonazepam or Baclofen) can give relief
  • Psychological Rx : hypnosis, behaviour modification, group therapy

 

Occasionally anxiolytic medications (diazepam 5mg 1 hour before sleep, then 2mg twice daily, for up to 10 days maximum) can be useful. Antidepressant medication (tricyclics) where indicated. Occlusal adjustment of the natural teeth by selective grinding is irreversible and not recommended.

Surgery may be required for the very small number of non-responders, especially those with obvious intra-articular pathology (osteoarthritis)

e.g. condylotomy, capsular rearrangement, silicone/teflon implants, auriculotemporal nerve section.