Temporomandibular joint dysfunction

Temporomandibular joint also called TMJ or jaw joint is a modified hinge joint that connect your lower jaw bone (the mandibular condyle of the mandible) to your skull (the mandibular fossa of the temporal bone of the skull) (Figure 1). You have two TMJs; one on each side of your jaw. You can feel your temporomandibular joint (TMJ) by placing your fingers in front of your ears and opening your mouth. The temporomandibular joint (TMJ) is formed by the condylar process of the mandible and the mandibular fossa and articular tubercle of the temporal bone (Figure 1). The temporomandibular joint (TMJ) is the only freely movable joint between your skull bones with the exception of the ear ossicles (all other skull joints are sutures and therefore immovable or slightly movable). The temporomandibular joint (TMJ) combines a hinge action with sliding motions, more specifically, they are the joints that slide and rotate in front of each ear. The parts of the bones that interact in the temporomandibular joint (TMJ) are covered with cartilage and are separated by a small shock-absorbing disc called articular disc, which normally keeps the movement smooth. The temporomandibular joint (TMJ) along with several muscles, allow your lower jaw bone (the mandible) to move up and down, side to side, and forward (anteriorly) and back (posteriorly). When your lower jaw bone (the mandible) and the temporomandibular joints (TMJs) are properly aligned, smooth muscle actions, such as chewing, talking, yawning, and swallowing, can take place. When these structures (muscles, ligaments, disk, jaw bone, temporal bone) are not aligned, nor synchronized in movement, several problems may occur.

Because of its shallow socket, the TMJ (temporomandibular joint) is the most easily dislocated joint in your body. Even a deep yawn can dislocate the TMJ (temporomandibular joint). The temporomandibular joint (TMJ) almost always dislocates anteriorly (towards the front); the condylar process of the mandible glides anteriorly (towards the front), ending up in the infratemporal fossa of your skull leaving your mouth wide open and unable to close. To realign, your doctor or dentist places his or her thumbs in your mouth between the lower molars and the cheeks, and then pushes the mandible inferiorly (towards the ground) and posteriorly (backwards).

Temporomandibular joint dysfunction (TMJD) also called temporomandibular disorders (TMD) is the collective term for a group of more than 30 conditions that cause pain and dysfunction in your jaw joint and muscles that control jaw movement ¹, ², ³, ⁴, ⁵, ⁶, ⁷, ⁸, ⁹. Individuals with temporomandibular disorders (TMD) commonly also have other painful and non-painful comorbidities including headaches, migraine, fibromyalgia, irritable bowel syndrome, tinnitus, chronic fatigue syndrome, depression and sleep disturbance ¹⁰. As seen with other chronic pain conditions, TMD are influenced by biopsychosocial factors ¹¹.

There are 3 main classes of temporomandibular disorders ⁸, ¹²:

1. Disorders of the temporomandibular joint, including articular disc disorders. Articular disk displacement involving the condyle–disk relationship is the most common intra-articular cause of TMD ¹³.
2. Disorders of the muscles used for chewing (masticatory muscles). Musculoskeletal conditions are the most common cause of TMD, accounting for at least 50% of cases ¹⁴, ¹⁵.
3. Headaches associated with a temporomandibular disorder (TMD).

A person with temporomandibular joint dysfunction may have one or more of these conditions at the same time.

Temporomandibular disorders (TMDs) are disorders of your jaw muscles, your temporomandibular joints (TMJs) and the nerves near your temporomandibular joints (TMJs). In other words, any problem that prevents the complex system of jaw muscles, jaw bones, and temporomandibular joints (TMJs) from working together in harmony may result in a temporomandibular disorder (TMD). Temporomandibular disorders (TMD) can cause pain in your temporomandibular joint (TMJ), face pain and in the muscles that control your jaw movement. Temporomandibular disorders (TMDs) are usually caused by painful spasms of the muscles that you use for chewing, can result from stress-induced teeth grinding, an injury to the TMJ, or from poor closing of your teeth.

Temporomandibular disorders (TMD) or temporomandibular joint dysfunction symptoms may include ², ⁶:

• Pain or tenderness of your jaw.
• Painful clicking or popping in the jaw.
• Pain in one or both of the temporomandibular joints.
• Muscle pain that travels through your face, jaw, and/or neck.
• Aching pain in and around your ear.
• Difficulty chewing or pain while chewing.
• Aching facial pain.
• Locking of the joint, making it difficult to open or close your mouth.
• Stiff jaw and neck muscles.
• A change in the way the upper and lower teeth fit together.
• Chronic TMD pain can lead to long-term problems such as depression, anxiety, and frequent headaches.

The most common symptoms of temporomandibular disorders (TMD) are pain in your ear and face, tenderness of your jaw muscles, popping or clicking sounds when you open your mouth, and
stiffness of the temporomandibular joint (TMJ). TMJ disorders can also cause a clicking sound or grating sensation when you chew. But if there’s no pain or limitation of movement associated with your jaw clicking, you probably don’t need treatment for a TMJ disorder.

A recent study found that about 11-12 million adults in the United States had pain in the region of the temporomandibular joint (TMJ) ¹⁶, ¹⁷. Temporomandibular disorders (TMD) are twice as common in women than in men, especially in women between 35 and 44 years old ¹⁸, ¹⁹, ²⁰.

The exact cause of a person’s TMJ disorder is often difficult to determine ²¹, ²². It is now understood that temporomandibular disorder (TMD) is a complex disorder with multiple causes and, as with other forms of chronic pain, TMD is consistent with a biopsychosocial model of illness and includes biologic, environmental, social, emotional, and cognitive reasons ¹¹, ², ²³, ²⁴, ²⁵, ²⁶. Factors consistently associated with TMD include other pain conditions (e.g., chronic headaches), fibromyalgia, autoimmune disorders, sleep apnea, and psychiatric illness ²⁷, ²⁸, ²⁹. A prospective cohort study (a type of observational study that follows a group of people over a period of time, examining how certain factors (like exposure to a given risk factor) affect their health outcomes) with more than 6,000 participants showed a twofold increase in temporomandibular joint disorders in persons with depression and a 1.8-fold increase in myofascial pain in persons with anxiety ³⁰. Smoking is associated with an increased risk of temporomandibular disorders in females younger than 30 years ³¹.

Your pain may be due to a combination of factors, such as genetics, arthritis or jaw injury. Some people who have jaw pain also tend to clench or grind their teeth (bruxism), although many people habitually clench or grind their teeth and never develop TMJ disorders. Temporomandibular disorders (TMD) can occur alone or at the same time as other medical conditions such as headaches, back pain, sleep problems, fibromyalgia, and irritable bowel syndrome.

Before receiving treatment for temporomandibular disorders, you should know:

• Sounds without pain in the temporomandibular joints are normal, happen frequently, and do not need treatment.
• Signs and symptoms of TMD go away in many people without treatment.
• Because evidence is lacking for the majority of TMD treatments, experts strongly recommend staying away from treatments that cause permanent changes to the jaw joints, teeth, or bite; or that involve surgery.

In most TMD cases, the pain and discomfort associated with TMJ disorders is temporary and go away on their own and can be relieved with self-managed care or nonsurgical treatments. Treatment usually focuses on getting the jaw muscles to relax using massage, stretching the muscles, applying moist heat or ice, using muscle relaxant drugs, bite guards for sleeping, and adopting stress-management or relaxation techniques.

Routine home treatment can often relieve jaw pain include:

• Rest your jaw joint by eating soft foods.
• Use medicines such as ibuprofen for a short time in order to inflammation around the TMJ.
• Use either an ice or warm pack for 15 minutes several times a day over painful areas.
• Find ways to reduce stress in your life such as regular exercise.
• Splints, also called bite plates, can be helpful to alleviate TMD pain. Splints are clear pieces of plastic that fit between the upper and lower teeth. They can help reduce grinding and clenching.
• Seek care from specially trained physical therapists.

However, some temporomandibular disorders (TMD) cases can become chronic, or long lasting. Surgery is typically a last resort after conservative measures have failed and is usually reserved for correction of anatomic or disk problems. Surgical options include arthrocentesis, arthroscopy, and open joint surgery. Moreover, it’s important to be careful, because sometimes surgery or invasive procedure may not work or may even make your symptoms worse. Before any surgery or other procedure, it is very important to get opinions from more than one doctor and to completely understand the risks. If possible, get an opinion from a surgeon who specializes in treating temporomandibular disorders.

Figure 1. Temporomandibular joint (TMJ)

Footnotes: The temporomandibular joint (TMJ) lies just in front (anterior) to your ear. At the temporomandibular joint (TMJ), the condylar process of the mandible (lower jaw bone) joins with the lower (inferior) surface of the squamous temporal bone of your skull. The mandible’s (lower jaw bone) condylar process is eggshaped, whereas the articular surface on the temporal bone has a more complex shape: Posteriorly (in the back), it forms the concave mandibular fossa; Anteriorly (in front), it forms a dense knob called the articular tubercle. Enclosing the temporomandibular joint (TMJ) is a loose joint capsule (articular capsule), the lateral aspect of which is thickened into a lateral ligament. Within the joint capsule (articular capsule) is an articular disc, which divides the synovial cavity into superior and inferior compartments. The two surfaces of the articular disc allow distinct kinds of movement at the temporomandibular joint (TMJ). First, the concave inferior surface receives the condylar process of the mandible (lower jaw bone) and allows the hinge like movement of depressing and elevating the mandible (lower jaw bone). Second, the superior surface of the articular disc glides anteriorly (towards the front) with the condylar process when the mouth is opened wide. This anterior (towards the front) movement braces the condylar process against the dense bone of the articular tubercle, so that the mandible is not forced superiorly through the thin roof of the mandibular fossa when you bite hard foods such as nuts or hard candies. To demonstrate the anterior (forward) gliding of your mandible, place a finger on the condylar process of the mandible just anterior to your ear opening, and yawn. The superior compartment also allows for the side-to-side gliding movements of this joint. As the posterior teeth are drawn into occlusion during grinding, the mandible moves with a side-to-side motion called lateral excursion. This lateral joint movement is unique to the masticatory apparatus of mammals and is readily apparent as you chew.

Figure 2. Muscles for chewing food (mastication)

Footnotes: The mandible (lower jaw bone) is the strongest bone of the skull and the only one that can move significantly. The mandible (lower jaw bone) supports your lower teeth and provides attachment for muscles for chewing food (mastication) and facial expression. The mandible (lower jaw bone) horizontal portion, bearing the teeth, is called the body; the vertical to oblique posterior portion is the ramus and these two portions meet at a corner called the angle. The muscles that move the mandible (lower jawbone) at the temporomandibular joint (TMJ) are known as the muscles of mastication (chewing). Of the four pairs of muscles involved in chewing food (mastication), three are powerful closers of the jaw and account for the strength of the bite: masseter, temporalis, and medial pterygoid muscles. Of these, the masseter muscle is the strongest muscle of mastication. The medial and lateral pterygoid muscles assist in mastication by moving the mandible from side to side to help grind food. The masseter and temporalis muscles produce the up-and-down crushing action of your teeth, and the lateral and medial pterygoid muscles and masseters produce side-to-side grinding action. Additionally, the lateral pterygoid muscles protract (protrude) the mandible. Note the enormous bulk of the temporalis and masseter muscles compared to the smaller mass of the two pterygoid muscles. The masseter muscle has been removed lower image to illustrate the deeper pterygoid muscles.

Figure 3. Temporomandibular Disorders (TMD)

Footnote: * A person may have one or more of these conditions at the same time.

Will braces help my TMJ problem?

There is no scientific basis for orthodontic treatment of disorders of the temporomandibular joint. The National Institutes of Dental and Craniofacial Research Brochure ³³ states, “other irreversible treatments that are of little value – and may make the problem worse – include orthodontics to change the bite; restorative dentistry, which uses crown and bridge work to balance the bite; and occlusal adjustment, grinding down teeth to bring the bite into balance. Even when the TMJ problem has become chronic, most patients still do not need aggressive types of treatment.”

Can my wisdom teeth cause TMJ problem?

Impacted wisdom teeth do not cause TMJ problems. Wisdom (3rd molars) teeth only need to be removed when local events justify their extraction. This includes inflammation of the gums around the wisdom teeth, or their negative impact on the neighboring teeth. They should not be extracted as a treatment for TMJ problems.

Can you get TMJ-like symptoms after a bad car accident?

Yes, it is possible that your TMJ problems were caused by your auto accident. The rapid forward and then backward movement of your head at the time of impact (whiplash injury) can produce injury to the temporomandibular joints. Such injuries often remain undetected during the emergency room visit because other matters need immediate treatment and get all the attention. You should follow up with your doctor to determine what next steps he/she considers appropriate at this time.

Could removal of my wisdom teeth cause TMJ problem?

Lengthy dental work requiring the patient’s mouth to be open very wide for extended periods can cause or aggravate a TMJ problem. We frequently hear from patients who experienced their first symptoms after having their wisdom teeth extracted or other type of dental treatment. Clicking or locking is caused by a displacement of disc that is located in the TMJ. You should consult the doctor who removed your wisdom teeth regarding your problem.

I have a dislocated disc in my TMJ. Is this common?

Yes, a dislocated disc is common. However, a diagnosis of a dislocated disc isn’t an indication for treatment. If you have a dislocated disc but experience no pain and there is no clicking or only faint clicking, no treatment is needed. But if your dislocated disc causes pain and restricts movement you may require treatment.

I was diagnosed with a dislocated TMJ disc but have no pain. Should I proceed with treatment to reposition my disc?

Many people have a dislocated disc and don’t even realize it. You’re fortunate that you have no pain. Since you have no pain, you should be cautious about seeking treatment. There are many opinions regarding the clinical significance of displaced discs and, not surprisingly, treatments vary among practitioners. Moreover, there are clinical data that the disc displacement is not the cause of the pain, and that any restriction in range of motion will improve with time.

Is tinnitus (ringing in the ears) related to a TMJ problem?

Tinnitus is a sound heard in one or both ears when no external sound is present. It is often referred to as “ringing in the ears,” although some people hear hissing, roaring, whistling, chirping, or clicking sounds. Although it has been reported to occur in patients with TMJ disorders, its causes in most cases remains unknown. If management of the TMJ problem does not eliminate the tinnitus, an Ear, Nose, and Throat (ENT) doctor should be seen to determine if there is another cause for the tinnitus.

Temporomandibular joint dysfunction causes

The cause of temporomandibular disorders is multifactorial and includes biologic, environmental, social, emotional, and cognitive reasons ², ²³, ²⁴, ²⁵, ²⁶. Factors consistently associated with TMD include other pain conditions (e.g., chronic headaches), fibromyalgia, autoimmune disorders, sleep apnea, and psychiatric illness ²⁷, ²⁸, ²⁹, ³⁴. A prospective cohort study (a type of observational study that follows a group of people over a period of time, examining how certain factors (like exposure to a given risk factor) affect their health outcomes) with more than 6,000 participants showed a twofold increase in temporomandibular joint disorders in persons with depression and a 1.8-fold increase in myofascial pain in persons with anxiety ³⁰. Smoking is associated with an increased risk of temporomandibular disorders in females younger than 30 years ³¹.

Painful TMJ disorders can occur if:

• The TMJ articular disc erodes or moves out of its proper alignment
• The temporomandibular joint’s cartilage is damaged by arthritis
• The temporomandibular joint is damaged by trauma or other impact.

The National Institute of Dental and Craniofacial Research classifies temporomandibular joint disorders by the following ⁸:

• Myofascial pain. This is the most common form of TMD. It results in discomfort or pain in the fascia (connective tissue covering the muscles) and muscles that control jaw, neck and shoulder function.
• Internal derangement of the temporomandibular joint. This means a dislocated jaw or displaced disk (cushion of cartilage between the head of the jaw bone and the skull), or injury to the condyle (the rounded end of the jaw bone that articulates with the temporal skull bone).
• Degenerative temporomandibular joint disease. This includes osteoarthritis or rheumatoid arthritis in the jaw joint.

You can have one or more of these conditions at the same time.

Studies have shown that the following 30 health conditions can coexist with TMJ disorders ³⁵, ³⁶:

• Ankylosing spondylitis in other body joints
• Asthma
• Back, neck, and joint pain
• Chronic fatigue syndrome
• Ehlers-Danlos syndrome
• Endometriosis
• Fibromyalgia
• Irritable bowel syndrome
• Headaches
• Heart disease
• Hypertension
• Interstitial cystitis/painful bladder syndrome
• Juvenile idiopathic arthritis in other body joints
• Neural/sensory conditions
• Osteoarthritis in other body joints
• Poor nutrition due to alerted jaw function and/or pain while chewing
• Psoriatic arthritis in other body joints
• Respiratory conditions (e.g., sinus trouble, allergies or hives, asthma, tuberculosis, breathing difficulties)
• Rheumatoid arthritis in other body joints
• Sinusitis
• Sjogren’s syndrome
• Sleep disorders (e.g., insomnia, poor sleep quality, longer sleep latency, lower sleep efficiency)
• Somatic and psychological symptoms (e.g., depression, anxiety and post-traumatic stress disorder)
• Systemic lupus erythematosus
• Tinnitus
• Vertigo
• Vulvodynia

Not everyone who develops one of these conditions will go on to develop TMJ disorders, however many people with TMJ disorders do, particularly women.

Injury to the jaw or temporomandibular joint can lead to some temporomandibular disorders, but in most cases, the exact cause is not clear. For many people, symptoms seem to start without obvious reason. Recent research suggests a combination of genes, psychological and life stressors, and how someone perceives pain, may play a part in why a temporomandibular disorder starts and whether it will be long lasting.

Because temporomandibular disorders are more common in women than in men, researchers are exploring whether the differences in TMJ structure and mechanics between females and males may play a role.

Derangement of the Condyle-Disc Complex

The derangement of the condyle disc complex arises due to a breakdown in the rotational function of the disc ³⁷. This condition can result from the lengthening of ligaments (discal collateral and inferior retro-discal ligaments) or thinning of the posterior disc border. The contributing factors can be micro or macro trauma ³⁷.

Disc Dislocation with Reduction

Disc displacement can lead to partial or complete disarticulation of the disc from discal space in condyle–disc assembly ³⁷. When you close your mouth, the articular disc is displaced anterior to the condyle head; when you open your mouth, superior surface of the articular disc glides anteriorly (towards the front) with the condylar process ³⁸. This on and off disc movement explains the click, snap, or pop sound in the TMJ. This sound does not appear with every movement of the mandible but with some frequency ³⁸. A normal range of motion is expected since the articular disc reduces during condylar translation ³⁸. Jaw deviation while opening the mouth can occur; the interincisal distance of disc reduction during opening is greater than when the disc is dislocated during the closure.

The disc can sometimes fail to reduce with consequent mouth opening limitation. This is known as disc displacement with reduction with intermittent locking ³⁸.

Disc dislocation without reduction

When the articular disc fails to reduce repeatedly, causing a limited mouth opening, the diagnosis of disc displacement without reduction is given ³⁸. The repositioning of the disc can become problematic due to the loss of elasticity in the superior retro-discal lamina. This situation causes forward translation of the condyle forcing the disc in front of the condyle. It presents as a locked jaw during the closure, represented as difficulty in maximum opening. The normal jaw opening is around 35 to 45 mm, deflects towards the involved joint, and is associated with pain. The bilateral manipulation technique of loading the joint is painful due to the condyle position in the retro-discal tissues.

Structural incompatibility with articular surfaces

The disorder results from changes in the smooth sliding surfaces of the TMJ. The alteration causes friction stickiness and inhibits joint function. Structural incompatibility classifies as a deviation in form, adhesions, subluxation, and spontaneous dislocation.

Deviation in mandibular movements

The physiological aging or minor degeneration of the condyle, disc, and fossa can cause deviations and dysfunction, significantly affecting mandibular movements.

Adherences and Adhesions

An adherence represents a brief hold of the articular surfaces. Adhesion can happen between the condyle and disc or the disc and fossa. Adhesions result from a fibrous connective tissue or loss of lubrication between the structures. It is characterized by restriction in the normal translation of the condyle movement with no pain. In chronic situations, the patient senses an inability to get the teeth back to occlusion during the closure.

Subluxation

A subluxation is a partial dislocation of a joint. It is a non-pathologic condition, a repeatable clinical phenomenon characterized by a sudden forward movement of the condyle past the crest of the articular eminence during the final stages of mouth opening. The steep, short posterior slope of the articular eminence and the longer anterior slope – more superior to the crest – cause the condyle to subluxate. The examiner can witness it by requesting the patient to open wide, creating a small void or depression behind the condyle.

Luxation (dislocation)

A dislocation happens when the condyle moves in front of the articular eminence and cannot descend back to the normal position ³⁹. Dislocations result from the TMJ’s hyperextension, causing the fixing of the joint in an open position during the opening of the mouth. It can be partial (subluxation) or complete (luxation). It can be acute or chronic (protracted or recurrent), bilateral or unilateral ³⁹. Anterior teeth are usually separated, and the posterior teeth are closed. The patient will find difficulty closing the mouth and pain.

Inflammatory disorders of the temporomandibular joint

Temporomandibular joint disease of inflammatory origin characteristically presents with deep continuous pain commonly accentuated on functional movement. This constant pain can trigger secondary excitatory effects. It expresses as referred pain, sensitivity to touch, protective contraction, or a combination of these problems.

Inflammatory joints are classified according to the structures involved into synovitis, capsulitis, retro-discitis, and arthritis.

Synovitis or Capsulitis

Trauma can cause inflammation of the synovial tissues (synovitis) and the capsular ligament (capsulitis). It presents as continuous pain, tenderness on palpation, and limited mandibular movement. However, it isn’t easy to differentiate between these two entities clinically, and arthroscopy is helpful for diagnosis.

Retrodiscitis

It is caused by trauma or progressive disc displacement and dislocation. The patient complains of pain, which increases with clenching. Limited jaw movement, swelling of retro discal tissues, and acute malocclusion are associated with the disease.

Arthralgia

The pain originates in the jaw and is affected by jaw movement, function, or para-function. The pain can be replicated with provocative testing of the TMJ.

Arthritis

Arthritis is a common disease that causes joint inflammation, pain, stiffness, and swelling. Several arthritis can affect the TMJ, including traumatic arthritis, infectious arthritis, and rheumatoid arthritis. Pain originates in the joint, and features of inflammation or infection over the affected joint are usually seen, such as swelling, redness, or increased temperature. Further symptoms include dental occlusal changes, e.g., ipsilateral posterior open bite if intraarticular with unilateral swelling or effusion. This disorder is also known as synovitis or capsulitis, although these terms limit the sites of nociception. TMD is a localized condition; there should be no history of systemic inflammatory disease.

Osteoarthritis

Osteoarthritis is a chronic condition that causes the cartilage in joints to break down, resulting in pain, stiffness, and swelling. Osteoarthritis is the most common type of arthritis and can affect the knees, hands, hips, spine, and ankles. Osteoarthritis is an inflammatory disorder that arises due to an increased joint overload. The increased forces soften the articular surfaces and resorb the subarticular surface. The progressive loading and the subsequent regeneration cause loss of the subchondral layer, bone erosion, and osteoarthritis. The condition characterizes by joint pain that increases with movement. It is also associated with disc dislocation and perforation.

Osteoarthrosis

Osteoarthrosis, also known as joint degeneration, is a common disorder that causes the cartilage in joints to break down over time. Osteoarthrosis is the adaptive unaltered arthritic changes of the bone due to decreased bone loading. It occurs after the overloading of the joint, mainly due to parafunctional activity, and is often associated with disc dislocation.

Chronic Mandibular Hypomobility

It is a long-term painless restriction of the mandible. Pain only occurs when using force to attempt opening beyond limitations. Hypomobility can be caused by ankylosis, muscle contracture, or coronoid process impedance.

Growth Disorders

Growth disturbances can affect the TMJ bones or muscles. Common growth disturbances of the bones are agenesis (no growth), hypoplasia (insufficient growth), hyperplasia (excessive growth), or neoplasia (uncontrolled, destructive growth). Common growth disturbances of the muscles are hypotrophy (weakened muscle), hypertrophy (increased size and strength of the muscle), and neoplasia (uncontrolled, destructive growth). The growth alterations typically result from trauma.

Risk factors for temporomandibular joint dysfunction

Factors that may increase the risk of developing temporomandibular disorders include ⁴⁰:

• Various types of arthritis, such as rheumatoid arthritis and osteoarthritis
• Jaw injury
• Long-term (chronic) grinding or clenching of teeth also called bruxism. Bruxism is a condition where a person involuntarily clenches, grinds, or gnashes their teeth. It can occur while a person is awake or asleep, but it’s more common during sleep.
• Certain connective tissue diseases that cause problems that may affect the temporomandibular joint (TMJ)

Temporomandibular joint dysfunction symptoms

Temporomandibular disorders (TMD) or temporomandibular joint dysfunction signs and symptoms may include ⁴¹, ⁴²:

• Pain in the chewing muscles and/or jaw joint (most common symptom).
• Pain in one or both of the temporomandibular joints.
• Painful clicking, popping, or grating in the jaw joint when opening or closing the mouth.
• Aching pain in and around your ear.
• Pain that spreads to the face or neck.
• Difficulty chewing or pain while chewing.
• Aching facial pain.
• Jaw stiffness.
• Limited movement or locking of the jaw, making it difficult to open or close your mouth.
• Tinnitus (ringing in the ears), hearing loss, or dizziness.
• A change in the way the upper and lower teeth fit together.

Temporomandibular disorders (TMD) can also cause a clicking sound or grating sensation when you open your mouth or chew. But if there’s no pain or limitation of movement associated with your jaw clicking, you probably don’t need treatment for a TMJ disorder.

Temporomandibular joint dysfunction complications

Temporomandibular disorder (TMD) classic triad includes pain in the temporomandibular joint, reduced mandibular range of motion, and functional clicking. This can impair patients’ capacity to perform everyday tasks such as eating, speaking, or yawning, significantly impacting their quality of life.

Temporomandibular joint dysfunction diagnosis

There is no widely accepted, standard test available to diagnose temporomandibular disorders (TMD). Because the exact causes and symptoms are not clear, identifying these disorders can be difficult.

Your doctor or dentist will take a detailed medical history, discuss your symptoms and examine your jaw. He or she will probably:

• Listen to and feel your jaw when you open and close your mouth
• Observe the range of motion in your jaw
• Press on areas around your jaw to identify sites of pain or discomfort
• He or she also will examine your head, neck and face for tenderness

If your doctor or dentist suspects a problem, you may need:

• Dental X-rays to examine your teeth and jaw
• Computed tomography (CT) scan to provide detailed images of the bones involved in the temporomandibular joint
• Magnetic resonance imaging (MRI) to reveal problems with the temporomandibular joint’s disk or surrounding soft tissue

TMJ arthroscopy is sometimes used in the diagnosis of a TMJ disorder. During TMJ arthroscopy, your doctor inserts a small thin tube (cannula) into the joint space, and a small camera (arthroscope) is then inserted to view the area and to help determine a diagnosis.

Temporomandibular joint dysfunction differential diagnosis

It is important to note that many face, ear, mouth and throat conditions can mimic TMJ disorders. Conversely, the assumption that TMD is the cause of a patient’s symptoms can result in a more sinister pathology being missed.

Temporomandibular joint dysfunction differential diagnosis include ³²:

• Dental conditions
  • Caries
  • Tooth abscess
  • Tooth eruption
• Ear conditions
  • Acute otitis media (middle ear infection)
  • Otitis externa (acute or malignant outer ear infection)
  • Mastoiditis
  • Eustachian tube dysfunction
• Headache disorder
  • Tension type headache
  • Migraine
  • Cluster headache
• Neurogenic conditions
  • Trigeminal neuralgia
  • Postherpetic neuralgia
  • Glossopharyngeal neuralgia
• Inflammatory conditions
  • Temporal arteritis
  • Rheumatoid arthritis
  • Systemic lupus erythematosus (SLE)
  • Parotitis
• Traumatic
  • Mandibular fracture/dislocation
  • Temporal bone fracture
• Other
  • Atypical facial pain
  • Sinusitis
  • Eagle syndrome (stylohyoid syndrome)

Temporomandibular joint dysfunction treatments

In some cases, the symptoms of TMJ disorders may go away without treatment. If your symptoms persist, your doctor or dentists may recommend a variety of treatment options, often more than one to be done at the same time.

Temporomandibular joint dysfunction home remedies

Because many jaw joint and muscle problems are temporary and do not get worse, simple treatment may be all that is necessary. Becoming more aware of your tension-related habits like clenching your jaw, grinding your teeth or chewing pencils will help you reduce their frequency. The following tips may help you reduce symptoms of TMJ disorders:

• Avoid overuse of jaw muscles. Eat soft foods. Cut food into small pieces. Steer clear of sticky or chewy food. Avoid chewing gum.
• Stretching and massage your jaw muscles. Your doctor, dentist or physical therapist may show you how to do exercises that stretch and strengthen your jaw muscles and how to massage the muscles yourself.
• Heat or cold. Applying warm, moist heat or ice to the side of your face may help alleviate pain.
• Eat soft foods.
• Reduce habits such as jaw clenching, gum chewing, or nail biting.

TMJ disorders alternative medicine

Complementary and alternative medicine techniques may help manage the chronic pain often associated with TMJ disorders. Examples include:

• Acupuncture. A specialist trained in acupuncture treats chronic pain by inserting hair-thin needles at specific locations on your body.
• Relaxation techniques. Consciously slowing your breathing and taking deep, regular breaths can help relax tense muscles, which can reduce pain.
• Biofeedback. Biofeedback involves using sensors that monitor breathing, heart rate, muscle contraction, and temperature. For example, a sensor on your jaw can detect when you tighten your jaw muscles. With the help of a therapist, you can learn to notice the unwanted behavior and practice effective relaxation techniques.
• Transcutaneous electrical nerve stimulation (TENS). Transcutaneous electrical nerve stimulation (TENS) is a method of pain relief involving the use of a mild electrical current. A TENS machine is a small, battery-operated device that has leads connected to sticky pads called electrodes. You attach the pads directly to your skin. When the machine is switched on, small electrical impulses are delivered to the affected area of your body, which you feel as a tingling sensation. The electrical impulses can reduce the pain signals going to the spinal cord and brain, which may help relieve pain and relax muscles. They may also stimulate the production of endorphins, which are the body’s natural painkillers.

TMJ disorders medicine

Along with other nonsurgical treatments, these medications may help relieve the pain associated with TMJ disorders:

• Pain relievers and non-steroidal anti-inflammatory drugs (NSAIDs). If over-the-counter pain medications aren’t enough to relieve TMJ pain, your doctor or dentist may prescribe stronger pain relievers for a limited time, such as prescription strength ibuprofen. Patients with suspected early disk displacement, synovitis, and arthritis benefit from early treatment with NSAIDs. Despite the multiple choices of NSAIDs available, only naproxen (Naprosyn) has proven benefit in reduction of pain ⁴³.
• Tricyclic antidepressants (TCAs). Tricyclic antidepressants (TCAs) are a class of medications used to treat a variety of mental health conditions and chronic pain. For example, amitriptyline, desipramine (Norpramin), doxepin, and nortriptyline (Pamelor) are used mostly for depression, but in low doses, it’s sometimes used for TMD pain relief, bruxism control and sleeplessness.
• Muscle relaxants. Muscle relaxants are drugs that reduce muscle tone and can help with muscle spasms, pain, and hyperreflexia. These types of drugs are sometimes used for a few days or weeks to help relieve pain caused by TMJ disorders created by muscle spasms. Muscle relaxants can be prescribed with NSAIDs if there is evidence of a muscular component to TMJ disorders ⁴⁴.
• Benzodiazepines are also used, but are generally limited to two to four weeks in the initial phase of treatment ⁴⁵, ⁴⁶. Longer-acting agents with anticonvulsant properties (i.e., diazepam [Valium], clonazepam [Klonopin], gabapentin [Neurontin]) may provide more benefit than shorter-acting agents.

Medications that have limited or no effectiveness for the treatment of TMD include opioids, tramadol (Ultram), topical medications (e.g., capsaicin [Zostrix], lidocaine, diclofenac), and newer antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors) ⁴⁷, ⁴⁸, ⁴⁹.

Temporomandibular joint dysfunction therapies

TMJ disorders therapies include:

• Oral splints or mouth guards (occlusal appliances). Often, people with jaw pain will benefit from wearing a soft or firm device inserted over their teeth, but the reasons why these devices are beneficial are not well-understood.
• TMJ physical therapy. Along with exercises to stretch and strengthen jaw muscles, treatments might include ultrasound, moist heat and ice.
• Cognitive behavioral therapy (CBT). Cognitive behavioral therapy (CBT) is a type of psychotherapy that combines cognitive and behavioral therapy to treat a range of mental health and physical conditions. Cognitive behavioral therapy (CBT) is based on the idea that psychological issues are partly caused by unhelpful thinking patterns, learned behavior patterns, and problematic core beliefs. The goal of CBT is to help people learn to identify and challenge unhelpful thoughts, change their behavior, and have more control over their thoughts, feelings, and behaviors. Cognitive behavioral therapy (CBT) can help treat depression, anxiety, obsessive-compulsive disorder, PTSD, chronic pain, tinnitus, rheumatism, irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia, insomnia, and migraines.
• Counseling. Education and counseling can help you understand the factors and behaviors that may aggravate your pain, so you can avoid them. Examples include teeth clenching or grinding, leaning on your chin, or biting fingernails.

TMJ dysfunction physical therapy

The goal of physical therapy is to maintain, improve, or bring back movement and physical function. There are several types of physical therapy. One type is manual therapy, in which a therapist uses his/her hands to stretch the soft tissues and muscles around the temporomandibular joint. Manual therapy has been shown to help improve function and relieve pain.

Oral splints or mouth guards (intraoral appliances)

Oral splints or mouth guards (intraoral appliances) also known as nightguards, splints, stabilization appliances, occlusal splints, interocclusal splints, or bruxism splints are devices that fit over your teeth. They do not change the teeth or bite.

Temporomandibular joint disorders surgical procedures

When conservative methods don’t help temporomandibular disorders, your doctor or dentist might suggest procedures such as:

• Arthrocentesis. Arthrocentesis is a minimally invasive procedure that involves the insertion of small needles into the temporomandibular joint so that fluid can be irrigated through the joint to remove debris and inflammatory byproducts.
• Injections. In some people, corticosteroid injections into the temporomandibular joint may be helpful. Infrequently, injecting botulinum toxin type A (Botox, others) into the jaw muscles used for chewing may relieve pain associated with TMJ disorders.
• TMJ arthroscopy. In some cases, arthroscopic surgery can be as effective for treating various types of TMJ disorders as open-joint surgery. A small thin tube (cannula) is placed into the temporomandibular joint space, an arthroscope is then inserted and small surgical instruments are used for surgery. TMJ arthroscopy has fewer risks and complications than open-joint surgery does, but it has some limitations as well.
• Modified condylotomy. A modified condylotomy is a modification of the intraoral vertical ramus osteotomy (IVRO). The purpose of modified condylotomy is to achieve vertical condylar sag, thereby increasing temporomandibular joint space with the goals of restoring normal disk position, obtaining prompt pain relief, allowing for resolution and healing of arthritic lesions, and in some cases reversing degenerative joint ⁵⁰, ⁵¹. Modified condylotomy addresses the temporomandibular joint indirectly, with surgery on the mandible, but not in the joint itself. It may be helpful for treatment of pain and if locking is experienced.
• Open-joint surgery (arthrotomy). If your jaw pain does not resolve with more-conservative treatments and it appears to be caused by a structural problem in the temporomandibular joint, your doctor or dentist may suggest open-joint surgery (arthrotomy) to repair or replace the joint. However, open-joint surgery involves more risks than other procedures do and should be considered very carefully, after discussing the pros and cons.

Before having any of these procedures:

• Ask about simpler treatments and try those first.
• Ask your doctor or dentist to explain the procedure in detail in a way you can understand.
• Ask how the procedure will help improve your specific temporomandibular disorder (TMD).
• Ask about the risks.
• Get second opinions from qualified medical or dental specialists.

IMPORTANT: Before any surgery, including implant surgery, it is extremely important to get opinions from more than one doctor and to completely understand the risks. If possible, seek an opinion from a surgeon who specializes in treating temporomandibular disorders.

Occlusal treatments

Occlusion refers to how teeth fit together. For years it was thought that misaligned teeth (malocclusion) were a cause of temporomandibular dysfunction; however, there is no evidence to support this belief. Occlusal treatments modify your teeth and bite. Examples include:

• Placing crowns on the teeth.
• Grinding down the teeth.
• Using orthodontic treatment(s) to change the position of some or all teeth.

There is no evidence these occlusal treatments work, and they could make the problem worse ⁸.

Botulinum toxin

Botulinum toxin Type A (Botox) works by relaxing muscles. Botulinum toxin Type A (Botox) is FDA-approved for some medical conditions like migraines but not for temporomandibular disorders. Studies have looked at injecting botulinum toxin Type A into the chewing muscles to reduce muscle spasm and pain. However, the information from these studies is limited and it is not clear whether this medication works to relieve TMD symptoms.

Prolotherapy

Prolotherapy involves injecting a solution into the TMJ area that causes irritation, with the goal of triggering the body to respond by repairing the joint. Prolotherapy has shown promise specifically for TMDs in which the joint is out of its normal position (dislocation) or when the joint goes beyond its normal range of movement (hypermobility). However, there have been only a few small studies on this treatment for TMDs.

Arthrocentesis

Arthrocentesis is a minimally invasive treatment. In this procedure a needle is used to push liquid into the TMJ, washing the joint with the possibility of depositing a drug or other therapeutic substance. The pressure caused by the liquid removes scar-like tissue (adhesions). In addition, when the liquid is flushed out of the joint, it removes substances that cause inflammation. Arthrocentesis has been shown to help with pain relief and improve mouth opening in people whose temporomandibular disc is out of place; however, these effects do not last long.

Arthroscopy

During arthroscopy your doctor inserts an instrument with a tiny video camera into your jaw joint through tiny incisions in your skin. Your surgeon can diagnose problems such as a torn cartilage and damage to the surface of the joint. He or she might be able to remove adhesions or reposition the joint’s disc using surgical instruments through the scope ⁵². This procedure works moderately well in helping improve pain and function.

Open joint surgery

Open joint surgery gives access to the temporomandibular joint through a cut (incision) over the joint next to your ear. It’s important to know that surgery makes permanent changes to your temporomandibular joint. There are no long-term research studies on the safety of open surgery for TMDs or on how well it works to relieve symptoms.

Open joint surgery is usually reserved for severe TMD patients that have ²:

• Excess tissue or bone growth that stops the temporomandibular joint from moving or functioning properly.
• Destruction of the temporomandibular joint that cannot be fixed with other procedures.
• Fusion of the joint tissue, cartilage, or bone (ankylosis).
• Severe symptoms (pain and/or difficulty opening the mouth), despite trying other treatments.
• Inability to reach the joint with arthroscopy.
• Severely malpositioned or damaged disc, or severe bony changes.

If your doctor suggests surgery, be sure to ask:

• Why are you suggesting surgery?
• Are there other options besides surgery?
• How will it help me?
• What are the risks?

TMJ Implants

TMJ implants are artificial devices that are used to replace part of the jaw joint or the entire joint. There are currently three TMJ implants approved by the FDA.

TMJ implants might be considered when:

• There is an injury to the temporomandibular joint.
• There is a condition you’re born with (congenital condition) that needs to be repaired.
• The temporomandibular joint is frozen (ankylosis), commonly caused by injury or infection.
• There’s severe damage to the temporomandibular joint.
• There’s ongoing pain.
• All simpler treatments have been tried and have failed.

Some studies suggest that, when used in very specific cases, TMJ implants can improve function and quality of life. As with any surgery, proceed with caution.

Implants used many years ago and since taken off the market, did not help patients and left them with severe complications, including permanent damage to the jaw joint(s). Because of this, researchers have called for long-term studies to look at the safety and efficacy of the newer TMJ implants.

Temporomandibular joint dysfunction prognosis

Up to 40% of patients with temporomandibular joint dysfunction report the remission of symptoms without any intervention ⁵³ and most patients have a favorable response to conservative treatment ³². A small number of patients develop refractory or persistent TMD. There are no known risk factors associated with chronic TMD. But, recently published data correlated heightened sympathetic tone with chronic TMJ pain ⁵⁴.

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