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Temporal–Mandibular Joint Injury/Syndrome, Emergency Medicine

Basics

Description

- Trauma - TMJ hypermobility: - Laxity - Dislocation - Subluxation

- TMJ hypomobility: - Infection - Neoplasm

- Intra-articular disk disorder: - Anterior displacement with reduction: - Displacement in closed mouth position - Often with a click and variable pain with opening mouth - May worsen over time

- Preauricular pain: - Constant but with fluctuating intensity - Dull and aching - May be referred to the ipsilateral ear, head, neck, or periorbital region - Exacerbated by mandibular movement (pathognomonic) - More conspicuous at night and may cause insomnia - Often worsens through the day

- Acute therapeutic options: - Patient reassurance and education " пїЅ " пїЅusually mild and self-limited " пїЅ - Rest - Heat - Analgesics and anxiolytics - Urgent reduction of open or closed locking TMJ - Reduction of TMJ dislocation: - Dislocation usually bilateral - IV muscle relaxant may be helpful - Often requires procedural sedation - Monitor airway - May face the patient or perform from behind the patient - Protect thumbs with gauze and/or tongue depressors - Thumbs rest on intraoral surface of mandible - Fingers wrap around jaw - Firm, progressive downward pressure as jaw is guided 1st in a caudal direction and then posteriorly

- Home physical therapy " пїЅmoist heat or ice packs and mechanically soft diet - Caution not to open mouth >2 cm for 2 wk - Avoid triggers such as gum chewing - Occlusal appliance worn during sleep - Referral to dentist or oral " пїЅmaxillofacial surgeon

  • Myofascial pain causing temporomandibular joint (TMJ) dysfunction
  • Prevalence of 40 " пїЅ75% of 1 sign of TMJ disorder
  • Most common in 20 " пїЅ50-yr-olds
  • Females seek treatment more frequently
  • 40% have symptoms that resolve spontaneously
  • TMJ is a synovial joint:Allows for hinge and sliding movements
  • Articular disorders:Congenital or developmentalDegenerative joint disorders:Inflammatory (rheumatoid arthritis)Noninflammatory (osteoarthritis)TraumaTMJ hypermobility:LaxityDislocationSubluxationTMJ hypomobility:InfectionNeoplasm
  • Masticatory muscle disorders:Local myalgiasMyositisMuscle spasmContractureMyofascial pain disorder
  • TMJ clicking:May be normal finding; present as a transient finding in 40 " пїЅ60% of the population
  • TMJ motion:Typical range is 35 " пїЅ55 mm (maxillary to mandible incisors)Limited by adhesions within the joint or disk displacement or trismus from muscle spasm
  • Intra-articular disk disorder:Anterior displacement with reduction:Displacement in closed mouth positionOften with a click and variable pain with opening mouthMay worsen over timeAnterior disk displacement without reduction:Disk is a mechanical obstruction to opening mouthMaximal opening may be 20 " пїЅ25 mmOften difficult to correct

Etiology

TMJ dysfunction is poorly understood: пїЅ пїЅ

  • Multifactorial:Bruxism (teeth grinding)TraumaMalocclusion
  • Onset may be related to stress

Diagnosis

Signs and Symptoms

History

  • Preauricular pain:Constant but with fluctuating intensityDull and achingMay be referred to the ipsilateral ear, head, neck, or periorbital regionExacerbated by mandibular movement (pathognomonic)More conspicuous at night and may cause insomniaOften worsens through the day
  • Tongue, lip, or cheek biting
  • Ear pain
  • Ear fullness
  • Tinnitus
  • Dizziness
  • Neck pain
  • Headache
  • Eye pain

Physical Exam

  • Joint sounds:Popping or clicking sensation with TMJ articulationA palpable or audible click with opening and closingNot sufficient for diagnosis if not accompanied by pain or other dysfunction
  • Misalignment and limited range of motion:Dentoskeletal malocclusion or lateral deviationOpen or closed locking of the jaw
  • Tenderness over the muscles of mastication and TMJ:Masseter muscle most commonly painful
  • Pain with dynamic loading (bite on gauze)

Essential Workup

  • Diagnosis based on history and physical exam
  • Exclude other causes of headache and facial pain

Diagnosis Tests & Interpretation

Lab

No specific lab tests are indicated unless there is concern for other disease process, i.e., ESR may help distinguish temporal arteritis from TMJ dysfunction. пїЅ пїЅ

Imaging

  • Panorex is the screening radiograph of choice:May demonstrate fracture or intra-articular pathology (i.e., tumor or degenerative joint disease) but usually unremarkable
  • CT: Best for evaluating bony structures for fractures, dislocations, etc.
  • MRI: Best imaging for nonreducing displaced disks:Allows for better visualization of joints simultaneously

Differential Diagnosis

  • Acute coronary syndrome
  • Carotid artery dissection
  • Intracranial hemorrhage (subarachnoid hemorrhage)
  • Inflammatory diseases:Giant cell (temporal) arteritisRheumatoid arthritis
  • Trigeminal or glossopharyngeal neuralgia
  • Vascular headache
  • Intraoral and dental pathology
  • Herpes zoster
  • Salivary gland disorder
  • Otitis media, otitis externa
  • Sinusitis
  • Elongated styloid process pain
  • Jaw trauma (fracture or dislocation)

Treatment

Pre-Hospital

Provide comfort and reassurance пїЅ пїЅ

Initial Stabilization/Therapy

Make sure airway is patent пїЅ пїЅ

Ed Treatment/Procedures

  • Acute therapeutic options:Patient reassurance and education " пїЅ " пїЅusually mild and self-limited " пїЅRestHeatAnalgesics and anxiolyticsUrgent reduction of open or closed locking TMJReduction of TMJ dislocation:Dislocation usually bilateralIV muscle relaxant may be helpfulOften requires procedural sedationMonitor airwayMay face the patient or perform from behind the patientProtect thumbs with gauze and/or tongue depressorsThumbs rest on intraoral surface of mandibleFingers wrap around jawFirm, progressive downward pressure as jaw is guided 1st in a caudal direction and then posteriorlyPhysical therapy " пїЅmoist heat or ice packsPain site injections with mixture of steroids/lidocaine
  • Outpatient management:Combination pharmacotherapy:NSAIDsMuscle relaxantsAntidepressantsSedative hypnoticsHome physical therapy " пїЅmoist heat or ice packs and mechanically soft dietCaution not to open mouth >2 cm for 2 wkAvoid triggers such as gum chewingOcclusal appliance worn during sleepReferral to dentist or oral " пїЅmaxillofacial surgeon

Medication

First Line

  • Naproxen: 250 " пїЅ500 mg PO BID (peds: 10 mg/kg/d PO div. q12h)
  • Cyclobenzaprine: 5 " пїЅ10 mg PO TID (peds: 5 " пїЅ10 mg PO TID if >15 yr old); caution with hepatic impairment
  • Diazepam: 2 " пїЅ10 mg PO BID " пїЅTID (peds: <12 yr old 0.12 " пїЅ0.8 mg/kg/d PO div. q6 " пїЅ8h); poor efficacy when used alone
  • Ibuprofen: 600 mg (peds: 10 mg/kg) PO q8h; less effective than naproxen

Second Line

  • Nortriptyline: 10 " пїЅ50 mg PO qhs
  • Narcotic analgesic
  • Sedative hypnotics

Follow-Up

Disposition

Admission Criteria

TMJ syndrome can be managed on an outpatient basis unless a locked or dislocated joint cannot be reduced пїЅ пїЅ

Discharge Criteria

Treat as outpatient with pain medication, muscle relaxants, and warm compresses пїЅ пїЅ

Followup Recommendations

Patients with TMJ syndrome may need referral to ENT, oral surgeon, or dentist for further care пїЅ пїЅ

Pearls and Pitfalls

  • TMJ locking must be addressed urgently
  • If ear pain with no ear findings, evaluate for TMJ
  • NSAIDs, rest, and heat are 1st-line therapy

Additional Reading

  • Buescher пїЅ пїЅJJ. Temporomandibular joint disorders. Am Fam Physician. 2007;76:1477 " пїЅ1482.
  • Gordon пїЅ пїЅSM, Viswanath пїЅ пїЅA, Dionne пїЅ пїЅRA. Evidence for drug treatments for pain related to temporomandibular joint disorder. TMJ News Bites, Newsletter of the TMJ Association, 3:6, Sept 2011.
  • Heitz пїЅ пїЅCR. Face and jaw emergencies. In: Tintinalli пїЅ пїЅJE, Stapczynski пїЅ пїЅJS, Cline пїЅ пїЅDM, et al., eds. Tintinallis Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011.
  • Lewis пїЅ пїЅEL, Dolwick пїЅ пїЅMF, Abramowicz пїЅ пїЅS, et al. Contemporary imaging of the temporomandibular joint. Dent Clin North Am. 2008;52:875 " пїЅ890.
  • Marx пїЅ пїЅJA, Hockberger пїЅ пїЅRS, Walls пїЅ пїЅRM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
  • Scrivani пїЅ пїЅSJ, Keith пїЅ пїЅDA, Kaban пїЅ пїЅLB. Temporomandibular disorders. N Engl J Med. 2008;359:2693 " пїЅ2705.

Codes

ICD9

  • 524.60 Temporomandibular joint disorders, unspecified
  • 524.62 Temporomandibular joint disorders, arthralgia of temporomandibular joint
  • 524.64 Temporomandibular joint sounds on opening and/or closing the jaw
  • 524.63 Temporomandibular joint disorders, articular disc disorder (reducing or non-reducing)
  • 524.61 Temporomandibular joint disorders, adhesions and ankylosis (bony or fibrous)
  • 524.69 Other specified temporomandibular joint disorders
  • 524.6 Temporomandibular joint disorders

ICD10

  • M26.60 Temporomandibular joint disorder, unspecified
  • M26.62 Arthralgia of temporomandibular joint
  • M26.69 Other specified disorders of temporomandibular joint
  • M26.63 Articular disc disorder of temporomandibular joint
  • M26.61 Adhesions and ankylosis of temporomandibular joint
  • M26.6 Temporomandibular joint disorders

SNOMED

  • 386207004 Temporomandibular joint-pain-dysfunction syndrome (disorder)
  • 91943004 Arthralgia of temporomandibular joint (disorder)
  • 196432004 temporomandibular joint click (disorder)
  • 91945006 Articular disc disorder of temporomandibular joint (disorder)
  • 109660007 Temporomandibular joint disc displacement (disorder)
  • 298373009 temporomandibular joint locking (finding)
  • 41888000 Temporomandibular joint disorder (disorder)
  • 50603008 Ankylosis of temporomandibular joint (disorder)
  • 91866004 Adhesions of temporomandibular joint (disorder)