Basics
Description
- Myofascial pain causing temporomandibular joint (TMJ) dysfunction
- Prevalence of 40 " �75% of 1 sign of TMJ disorder
- Most common in 20 " �50-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 developmental
- Degenerative joint disorders:
- Inflammatory (rheumatoid arthritis)
- Noninflammatory (osteoarthritis)
- Trauma
- TMJ hypermobility:
- Laxity
- Dislocation
- Subluxation
- TMJ hypomobility:
- Infection
- Neoplasm
- Masticatory muscle disorders:
- Local myalgias
- Myositis
- Muscle spasm
- Contracture
- Myofascial pain disorder
- TMJ clicking:
- May be normal finding; present as a transient finding in 40 " �60% of the population
- TMJ motion:
- Typical range is 35 " �55 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 position
- Often with a click and variable pain with opening mouth
- May worsen over time
- Anterior disk displacement without reduction:
- Disk is a mechanical obstruction to opening mouth
- Maximal opening may be 20 " �25 mm
- Often difficult to correct
Etiology
TMJ dysfunction is poorly understood: � �
- Multifactorial:
- Bruxism (teeth grinding)
- Trauma
- Malocclusion
- Onset may be related to stress
Diagnosis
Signs and Symptoms
History
- 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
- 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 articulation
- A palpable or audible click with opening and closing
- Not sufficient for diagnosis if not accompanied by pain or other dysfunction
- Misalignment and limited range of motion:
- Dentoskeletal malocclusion or lateral deviation
- Open 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. � �
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) arteritis
- Rheumatoid 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 � �
Initial Stabilization/Therapy
Make sure airway is patent � �
Ed Treatment/Procedures
- Acute therapeutic options:
- Patient reassurance and education " � " �usually mild and self-limited " �
- 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
- Physical therapy " �moist heat or ice packs
- Pain site injections with mixture of steroids/lidocaine
- Outpatient management:
- Combination pharmacotherapy:
- NSAIDs
- Muscle relaxants
- Antidepressants
- Sedative hypnotics
- Home physical therapy " �moist 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 " �maxillofacial surgeon
Medication
First Line
- Naproxen: 250 " �500 mg PO BID (peds: 10 mg/kg/d PO div. q12h)
- Cyclobenzaprine: 5 " �10 mg PO TID (peds: 5 " �10 mg PO TID if >15 yr old); caution with hepatic impairment
- Diazepam: 2 " �10 mg PO BID " �TID (peds: <12 yr old 0.12 " �0.8 mg/kg/d PO div. q6 " �8h); poor efficacy when used alone
- Ibuprofen: 600 mg (peds: 10 mg/kg) PO q8h; less effective than naproxen
Second Line
- Nortriptyline: 10 " �50 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 � �
Discharge Criteria
Treat as outpatient with pain medication, muscle relaxants, and warm compresses � �
Followup Recommendations
Patients with TMJ syndrome may need referral to ENT, oral surgeon, or dentist for further care � �
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 � �JJ. Temporomandibular joint disorders. Am Fam Physician. 2007;76:1477 " �1482.
- Gordon � �SM, Viswanath � �A, Dionne � �RA. Evidence for drug treatments for pain related to temporomandibular joint disorder. TMJ News Bites, Newsletter of the TMJ Association, 3:6, Sept 2011.
- Heitz � �CR. Face and jaw emergencies. In: Tintinalli � �JE, Stapczynski � �JS, Cline � �DM, et al., eds. Tintinallis Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill; 2011.
- Lewis � �EL, Dolwick � �MF, Abramowicz � �S, et al. Contemporary imaging of the temporomandibular joint. Dent Clin North Am. 2008;52:875 " �890.
- Marx � �JA, Hockberger � �RS, Walls � �RM, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. St. Louis, MO: Mosby; 2009.
- Scrivani � �SJ, Keith � �DA, Kaban � �LB. Temporomandibular disorders. N Engl J Med. 2008;359:2693 " �2705.
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)