Temporomandibular Joint (Jaw)dysfunction

Definition:

‘An umbrella term relating to mechanical and psychological pain and dysfunction of the Temporomandibular joint, it’s associated muscles involved in mastication and other functional mobilisations of the mandible’

Key Points:

Pain can be significant / absent and cause functional impairment

Pain can be both mechanically and psychologically driven

Associated with other symptoms including headache and neck pain

Crosses inter-disciplinary boundaries

Variety of treatments available

Diagnosis can be complex – treatment often difficult

Incidence:  

20-30% of population estimated to have some symptoms of TMJ  

Only 10% will seek medical advice

Gender: females > males (4:1) !?!?!?!?!?!?!?

Radiology: X-Ray - Changes in 14- 44% of the population (greater in older groups, lower incidence of symptoms) 

MRI – high % disc diplacement in healthy

Age: highest incidence young adults 20-40 yrs

Contributing factors:

Existing Joint degeneration 

Posture – Forward head position  and Rounded Shoulders 

History of Whiplash (Grongvist et al, 2008) 

Trauma – Direct i.e Blow to face, Jaw 

Bruxism (sub-conscious jaw movements) Stress related!

Jaw Malalignment 2ndy to poor dental condition/absence

Hypermobility syndrome

30% increase with HRT

20% increase with Cotraceptive (Roda et al, 2007 )

Ehlers-Danlos syndrome, Marfan syndrome or other connective tissue disorders

Symptoms:

Jaw / facial pain/tenderness Sudden onset of pain

Ache may radiate to face, ear, head Dysfunction or pain with chewing

Clicking / Popping Dysphagia Crepitation

Loss of mouth opening range Unable to Fully close mouth

Misalignment/deviation Fatigue with Jaw movement 

Associated Head (80%), Ear (40%) Neck pain

Diagnosis:

Myofascial – local and global muscles:

Dull Pain and soreness exacerbated by chewing or yawning  

Headache 

Pain located in the temples and masseter regions  

Linked to stress  

Morning pain

Possible restriction of movement

Possible deviation

Possible clicking on opening. 

Examination:   

Tenderness of joint  

Tender muscles

Signs of tooth grinding likely

Tenderness of neck musculature common  - may reflect stress as a cause.

Degeneration – joint surfaces, disc

Inflammatory arthritis possible in associaition with other joints.  

Possible history of recurrent trauma

Possible history of TMJ pain

Graduated onset with possible exacerbations.  

Particularly stiff mornings

Patients 55+

Limitation in ranges

Capsular pattern

Crepitations through ranges.

Synovitis – capsular inflammation

Probable trauma related

Acute onset

Pain on closing of joint

Swelling and tenderness

Crepitation through movement

Restricted movement

Disc dysfunction - Internal Derangement of disc

Can occur as a result of hypermobility

Congenital abnormality

Trauma

Long term muscle imbalance

Abnormal joint function i.e. clicking or locking 

Jaw may click on opening or closing – disc relocating

Symptoms can be progressive.

Clicking present with and without pain.

Pain occurs only if capsular extensions involved – disc is avascular and absent of neural tissue.

May occur Acutely and present as closed lock.

Typically, discs displace anteriorly.  There are two types:

a) Reducing: Loud click or pop with opening (disc relocated) or when closing.

b) Non-reducing:   Restrictions without noise

Other potential diagnoses:

Otitis Media/Externa (swimmer's ear)

Tooth ache

Trigeminal neuralgia

Tumour

Fracture

Treatment:

Postural exercises:  

Effective in the treatment of Myogenous TMD – (Wright et al, 2000; Komiyama et al, 1999 – results favourable however poor methodology) related to myogenous pain 

(also Medlicott and Harris, 2006)

Manual therapy: 

Effective with exercise and positioning splint (Carmeli et al, 2001).

Directed at cervical spine.  Reported reduction in Myofascial TMD pain.  Also included cervical and postural exercises. (La Touche Et al, 2009)

Manual therapy, exercises and posture:

Equal effectiveness of therapies with improvements in all. Mixed pathology

(Medlicott and Harris, 2006)

Acupuncture: 

Compared with sham and Splint therapy.

Significatly better than control.  No difference between Sham and control group 

No better than splint therapies     (Kulckcioglu et al, 2003; list et al, 1993;)

Simma et al (2009) reported reduced pain in acupuncture compared to placebo.

(Medlicott and Harris, 2006)

Overall a mix of treatments are effective but the causes behind the problem need to be corrected otherwise it will be very difficult to resolve the symptoms fully.