Temporomandibular Joint
disorders
DIAGNOSTIC FEATURES
5 signs
- Pain on palpation of TMJ
- Pain on palpation of associated muscles
- Limitation or deviation of mandibular movement
- Joint sounds
- Headache
Note headache and joint sounds alone are not
diagnostic
Refer to dental surgeon, Oral
Maxillofacial Surgeon (OMFS) or Oral Medicine specialists care (Adelaide Dental Hospital)
CAUSES
Often Multi-factorial -
psychological, traumatic and occlusal
Types
- Extracapsular dysfunction - muscle hyperactivity
- Intracapsular dysfunction - internal derangement
or pathology of the joint
- Osteoarthritis Osteoarthritis (crepitations, limitation of
jaw movement and pain is usually located to the immediate pre-auricular region and does
not radiate to areas of muscle attachment)
- Internal derangement Internal derangement ( click from the joint
due to a disc displacement or alternatively a mechanical obstruction to mouth opening.
Early stage pain is not a feature. Later pain appears due to muscle spasm.)
- Trauma Trauma (to face and or jaws. Pain is usually
self-limiting and resolves in 5-7 days)
- Dislocation Dislocation (rare in absence of anatomical
defect and usually associated with trauma when pt is hit with mouth open)
- Rheumatoid arthritis/ Psoriatic arthritis Rheumatoid arthritis/ Psoriatic arthritis (
Uncommon)
- Developmental defects Developmental defects (rare - ankylosis,
infection, neoplasia)
Precipitants
Stress (common) - ?inducing parafunctional
activity (e.g. clenching, bruxism) inducing pain and spasm of the masticatory muscles and
also centrally by decreasing the pain threshold
Associated conditions
- Back pain, headaches, and migraine (frequent)
ASSESSMENT
Screening questions
- Do you have difficulty or pain, or both. When
opening your mouth, as for instance when yawning?
- Does your jaw get ,stuck, locked, or go out?
- Do you have difficulty or pain, or both, when
chewing, talking, or using your jaws?
- Are you aware of noises in the jaw joints?
- Do you have pain or about the ears, temples or
cheeks?
- Does your bite feel uncomfortable or unusual?
- Do you have frequent headaches?
- Have you had a recent injury to your head, neck,
or jaw?
- Have you previously been treated for a jaw
problem? If so when?
Further assessment if:
- Any positive answer to Question 1-3
- Two positive answers to Questions 4 -8 (even if
positive answer to Question 9)
Screening examination procedures for TMJD
- Measure range of motion of the mandible on opening
and right and left laterotrusion.
- Palpate for preauricular TMJ tenderness
- Palpate for TMJ crepitus
- Palpate for TMJ clicking
- Palpate for tenderness in the masseter and
temporalis muscles
- Note excessive occlusal wear, excessive tooth
mobility, fremitus or migration of tooth/ teeth in the absence of periodontal disease, and
soft tissue alternations (look for buccal mucosal ridging, lateral tongue scalloping)
- Inspect symmetry and alignment of the face, jaws,
and dental arches
Further investigation if:
- Any positive finding to Question 1-3
- Two positive findings from Question 4-6 (even if
Question 7 is positive)
IMAGING
Indicated only if clinical exam suggests
bone/joint swelling/deformity
MANAGEMENT
Sequence of treatment
- Treatment of symptoms
- Treatment of underlying cause
- Treatment of predisposing factors
- Treatment of pathological effects
- Reassurance and explanation
- Avoid stress/clenching/ bruxism
- Emphasize rest
- Muscle relaxing exercises
- Stand in front of the mirror
- Open mouth against resistance e.g. open mouth
against a clenched fist pushing the opposite way (hold for 10 sec)P
- Push jaw laterally against resistance with clench
fist
- Do 20 sets, bd
- (Adelaide Dental Hospital Out-patients for copy of
jaw exercises sheet).
- Warm pack on the affected area
- Soft diet
- Physiotherapy
- Pharmacotherapy (Ibuprofen 400mg tds)
- For clenching/ bruxism dothiepin HCl 25 - 50 mg
mane or diazapam 5mg nocte
Follow-up
Dentist/Oral surgeon
Dr George Chu BDSc MBBS
Ed: Dr. Derek Louey MBBS FACEM