Temporomandibular Disorder

Temporomandibular Disorder

Temporomandibular disorders (TMD) are a diverse set of musculoskeletal and neuromuscular disorders affecting the temporomandibular joint complex, as well as adjacent muscles and bony components. TMD affects up to 17% of individuals, with a peak incidence between the ages of 20 and 40. TMD is divided into two categories: intra-articular and extra-articular. Jaw discomfort or dysfunction, earache, headache, and facial pain are all common symptoms. TMD has multifactorial causation that encompasses biological, environmental, social, emotional, and cognitive factors. The majority of diagnoses are made depending on the patient's medical record and physical examination. When malocclusion or intra-articular disorders are suspected, diagnostic imaging may be helpful. A combination of noninvasive interventions, such as patient education, self-care, cognitive behavioral therapy, medication, physiotherapy, and occlusal devices, improves the majority of patients. In the beginning, nonsteroidal anti-inflammatory medications and muscle relaxants are advised, with the addition of benzodiazepines or antidepressants in chronic situations. Refractory patients should be referred to an oral and maxillofacial surgeon.

The mandibular condyle inserts into the mandibular fossa of the temporal bone to produce the temporomandibular joint (TMJ). This joint's mobility is mostly controlled by the mastication muscles. Craniofacial pain affecting the joint, masticatory muscles, or muscle innervations of the head and neck is known as temporomandibular disorders (TMD). TMD is a common cause of orofacial pain that isn't caused by tooth decay. TMD affects 12% to 15% of individuals, according to population-based studies, although only 6% of them seek therapy. TMD is most common between the ages of 20 and 40; it is twice as common in women as it is in males, and it comes with a high financial cost due to lost employment. Symptoms might range from minor discomfort to excruciating pain, as well as jaw function impairments.

 

Temporomandibular Disorder Classification

classifications of TMD

The following are the three primary classifications of TMD along with instances of disorders within each class.

  • Joint disorders are a common occurrence. Joint discomfort (arthralgia), disc problems (disc not in its natural position), and bone deterioration (degenerative joint disease) are only a few examples.
  • Muscle disorders affecting the chewing muscles (masticatory muscles). Pain that diffuses beyond the spot where it begins or pain felt in an area of the body far away from where it began, and pain that is localized and worsens when applying pressure (myalgia).
  • Headaches as a result of TMD. Any form of headache combined with a painful TMD is an example.

Many TMD are only temporary and disappear on their own. They can, however, develop into a chronic or long-term issue in some circumstances. TMDs can also occur alone or in conjunction with other medical diseases such as headaches, back pain, insomnia, fibromyalgia, and irritable bowel syndrome. According to a recent study, around 12-13 million persons in the United States suffer from temporomandibular joint pain. Women are twice as likely as men to have temporomandibular problems, especially between the ages of 30 and 45.

 

Epidemiology

TMD

TMD primarily affects adults between the ages of 25 and 40, with an average age of 40 years. TMD is more common in younger persons who are otherwise healthy. There are peaks for disc displacements at age 32, and for inflammatory-degenerative joint problems at age 49, under the umbrella of TMD.

Approximately 78% of the general population has at least one aberrant indication related to the TMJ (e.g., popping), and approximately 34% has at least one TMD symptom. However, only 3.5-7% of the time will this be severe enough to prompt the individual to seek professional care.

Women are more likely than men to be impacted for unexplained causes, with a ratio of roughly 2.5:1., however, some sources claim the ratio is as high as 10:1. Women are more likely than men to seek TMD treatment, and their complaints are less likely to go away. TMD-affected females are more likely to be nulliparous than non-affected females. It has also been stated that female Caucasians are more likely than female African Americans to be impacted by TMD and at a younger age.

According to the most recent epidemiologic analysis of the data utilizing the TMD diagnostic criteria, muscle problems account for 45 percent of all TMD cases, disc displacements account for 41 percent, and joint abnormalities account for 30 percent (individuals may have diagnoses from more than one subtype). TMD has a prevalence in the overall population of 9.8% for group I, 11% for group II, and 2.7% for group III.

 

Temporomandibular Disorder Causes

TMD has a diverse etiology that encompasses biologic, environmental, social, emotional, and cognitive factors. Other pain problems (e.g., persistent headaches), fibromyalgia, immunological disorders, sleep apnea, and psychiatric disorders have all been linked to TMD. Prospective cohort research with over 6,000 participants found that people with depression had a twofold increase in TMD and a 2-fold increase in myofascial pain. In females under the age of 32, smoking has been linked to a higher risk of TMD.

 

Temporomandibular Disorder Differential Diagnosis

Physicians should be cautious when diagnosing TMD in patients who complain of TMJ pain. Dental caries or abscesses, oral lesions (e.g., herpes zoster, herpes simplex, oral aphthous ulcers, lichen planus), muscle misuse and abuse conditions (e.g., squeezing, jaw clenching, excessive chewing, spasm), trauma or dislocation, maxillary sinusitis, exocrine gland disorders, postherpetic neuralgia, and glossopharyngeal neuralgia. Autoimmune disorders like systemic lupus erythematosus, Sjogren syndrome, and rheumatoid arthritis can all cause TMD symptoms.

 

Temporomandibular Disorder Symptoms

Temporomandibular Disorder Symptoms

TMD is diagnosed mostly based on the patient's medical history and physical assessment findings. Jaw movement (e.g., opening and closing the mouth, chewing) and pain in the preauricular, masseter, or temple region are common TMD symptoms. If pain is not relieved by moving the jaw, another cause of orofacial pain should be considered. TMD can cause unusual jaw noises (e.g., clicking, snapping, grating, crepitus), although it can also happen in up to 55% of asymptomatic people.  The most prevalent presenting signs and symptoms, according to a major retrospective study performed by a single physician over a 25-year period, were facial pain (97 percent), ear discomfort (83 percent), headache (80 percent), and jaw discomfort or dysfunction (79 percent). Other signs and symptoms include dizziness and pain in the neck, eye, arm, or back. Chronic TMD is described as pain that lasts more than three months.

 

Temporomandibular Disorder Diagnosis

Physical Examination

Temporomandibular Disorder Diagnosis

Abnormal mandibular movements, reduced range of motion, tenderness of masticatory muscles, pain with dynamic loading, symptoms of bruxism, and neck or shoulder muscle tenderness are all clinical assessment findings that reinforce the diagnosis of TMD. Malocclusion (e.g., acquired edentulism, hemifacial asymmetry, restorative occlusal rehabilitation) might contribute to the appearance of TMD, thus physicians should look for it. TMD should not be blamed for cranial nerve problems. Joint dysfunction may be accompanied by clicking, crepitus, or locking of the TMJ. An anterior disk displacement could be indicated by a single click when expanding the mouth. Disk displacement with reduction occurs when a second click occurs during mouth closure, resulting in the recapture of the displaced disk. A closed lock occurs when disk displacement proceeds to the point that the patient is unable to fully open their mouth (i.e., the disk is impeding condyle translation). Crepitus is linked to articular surface disturbance, which is common in osteoarthritis patients.

Tenderness on manipulation of the TMJ that is reproducible is indicative of intra-articular abnormality. Myalgia, myofascial trigger points, or referred pain syndrome can all be distinguished by the tenderness of the masseter, temporalis, and adjacent neck muscles. During mouth opening, a deviation of the jaw toward the afflicted side could suggest anterior articular disk displacement.

 

Imaging Studies

Imaging Studies

When the history and physical exam findings are inconclusive, imaging might help with the diagnosis of TMD. Multiple imaging techniques are available to obtain further information about potential TMD etiologies, albeit they are rarely employed. Plain radiography (transcranial and trans-maxillary images) or panoramic radiography should be used for the initial examination. These examinations frequently reveal acute fractures, dislocations, and severe degenerative articular disease. When it comes to assessing delicate bony morphology, computed tomography outperforms standard radiography. In individuals with signs and symptoms of TMD, magnetic resonance imaging (MRI) is the best option for a complete joint examination. Although there is an 80 percent to 95 percent relationship between magnetic resonance imaging findings and joint morphology in symptomatic individuals, 20 percent to 35 percent of asymptomatic patients have false-positive findings. Magnetic resonance imaging is usually indicated for patients who have persistent symptoms, have failed to respond to conservative treatment, or have suspected internal joint abnormality. When magnetic resonance imaging is not feasible, ultrasonography provides a noninvasive, dynamic, and low-cost tool for diagnosing internal TMJ dysfunction. 

 

Diagnostic Injections

Local anesthetic injections at trigger sites involving the mastication muscles can be used as a diagnostic aid in determining the etiology of jaw pain. Only clinicians and dentists with experience anesthetizing the auriculotemporal nerve area should conduct this treatment. Complication rates are modest when conducted correctly. After proper nerve blocking, persistent pain should prompt the physician to review TMD symptoms and consider a different diagnosis.

 

Temporomandibular Disorder Treatment

Only around 7% to 10% of TMD patients require therapy, and 45% of individuals experience symptoms that go away on their own.

After conservative therapy, 55 percent to 90 percent of patients reported pain alleviation in a long-term follow-up study. For the treatment of TMD, an interdisciplinary approach is effective. The primary therapeutic goal should be to alleviate pain and dysfunction. Anti-inflammatory medications (75 percent), non-prescription pain medications (57 percent), antidepressants (52 percent), opioids (50 percent), anxiolytics (40 percent), and muscle relaxants (40 percent) were all reported by more than 1,500 people in an online TMD registry. Surgical treatment was only used in patients whose symptoms did not change after a trial of conservative treatment.

 

Non-pharmacological Treatment

treatment for TMD

The suggested first treatment for TMD is supportive patient education.  Jaw resting, a soft meal, moist warm compresses, and passive stretching exercises are all recommended as supplements. Because of muscle contractures, exhaustion, and decreased synovial fluid production, TMJ immobility has shown no benefit and may increase symptoms.

  • Physical therapy. It is a term that refers to the use of Physical treatment that has been shown to help people with TMD symptoms, albeit the evidence isn't strong. Techniques to improve muscle strength, synchronization, relaxation, and range of motion can be active or passive (e.g., scissor opening with fingers, use of medical instruments). Despite the lack of evidence to support their effectiveness, specialized physical therapy methods such as ultrasound, iontophoresis, electroshock treatment, or low-level laser therapy have been employed in the treatment of TMD. Treatment of underlying comorbid diseases increases the likelihood of TMD management success.
  • Acupuncture. Acupuncture is becoming more popular as a treatment for myofascial TMD. Sessions usually run 20 to 30 minutes, and there are six to eight of them on average. Acupuncture appears to be a viable supplementary treatment for short-term analgesia in individuals with painful TMD symptoms, according to two systematic evaluations.
  • Biofeedback. When compared to standard care, a Cochrane study supports the use of cognitive-behavioral therapy and biofeedback in both short- and long-term pain control for patients with symptomatic TMD. Patients should be advised on stress management, sleep hygiene, the reduction of parafunctional habits (e.g., teeth grinding, pencil or ice biting, teeth clenching), and the avoidance of excessive mandibular movement (e.g., excessive opening during yawning, teeth brushing, and teeth flossing).

 

Pharmacological Treatment

pharmacologic therapy for TMD

Expert opinion is heavily weighted in pharmacologic therapy for TMD. The underlying discomfort linked with TMD is treated with a variety of medications.

A Cochrane review of nonsteroidal anti-inflammatory drugs including salicylates and cyclooxygenase inhibitors, benzodiazepines, anti-epileptic treatments, and muscle relaxants found 2,280 papers, 11 of which were included in the qualitative synthesis.

There was inadequate evidence to support or disprove the efficacy of any medication for the treatment of TMD, according to the researchers.

NSAIDs are first-line pain relievers that are normally administered for 10 to 14 days to treat acute pain. Early treatment with NSAIDs is beneficial for patients with potential early disk displacement, synovitis, and arthritis. Despite the wide range of NSAIDs accessible, only naproxen has been shown to be effective in reducing pain. If there is an indication of a muscular component to TMD, muscle relaxants can be administered together with NSAIDs. Chronic TMD pain is treated with tricyclic antidepressants such as amitriptyline, desipramine, doxepin, and nortriptyline. Benzodiazepines are also utilized, but only for two to four weeks during the first treatment phase. Anticonvulsant drugs with a longer half-life (e.g., diazepam, clonazepam, gabapentin) may be more beneficial than those with a shorter half-life. Opioids are not suggested and should only be taken for a short length of time in the case of extreme pain in individuals who have failed to respond to non-opiate therapy. Even with these guidelines, opioids should be used with caution due to the risk of addiction.

Tramadol, topical medications (e.g., capsaicin, lidocaine, diclofenac), and modern antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, monoamine oxidase inhibitors). are all treatments that have poor or no benefit in the treatment of TMD.

The usefulness of onabotulinumtoxin A (Botox) in the treatment of TMD has been studied in a small number of studies. Early small randomized controlled trials for the treatment of painful myofascial symptoms have yielded promising outcomes. A recent Cochrane review, however, found insufficient evidence to support the use of onabotulinumtoxin A for myofascial pain. Only one of the four investigations found this method to be beneficial.

 

Occlusal Splints and Adjustments

Adjustments for TMD

Occlusal splints are hypothesized to reduce or eliminate the degenerative forces that are put on the TMJ, articular disk, and dentition. A small group of patients with severe bruxism and nighttime clenching may benefit from these devices. Systematic evaluations have provided inconsistent results when it comes to the best occlusal device for treating TMD symptoms. To identify the best occlusal device, you should seek dental advice. Occlusal modifications (grinding enamel surfaces to optimize dentition) are ineffective in treating or preventing TMD.

 

Temporomandibular Disorder Surgery

If the patient has a history of TMJ complex trauma or fracture, severe pain and impairment from internal derangement that does not respond to conservative measures, or pain with no identifiable cause that lasts more than three to six months, a referral to an oral and maxillofacial surgeon is preferred. TMD is seldom treated with surgery, which is mainly reserved for the correction of anatomic or articular deformities. Arthrocentesis, arthroscopy, condylotomy, and total joint replacement are all surgical alternatives.

Surgical treatments for TMD have been demonstrated to be effective in reducing symptoms and enhancing joint mobility, despite the fact that they are invasive. Patients with poor dental hygiene, dental caries, malocclusions, or tooth wear patterns that may be linked to TMD symptoms should be referred to a dentist.

 

Temporomandibular Disorder Treated in South Korea

Treated in South Korea

TMD or TMJ pain is linked to headaches, migraines, tinnitus (ringing in the ear), head and neck muscle strain, pain while chewing, the inability to open the mouth with a clicking sound, pain when opening or closing the jaw, tender points along the jaw muscles.

Dr. Raimund Royer (he is oriental medical doctor who treats Korean Medicine in musculoskeletal and neuromuscular disorders at the Jaseng Hospital of Korean Medicine) is specialized in the treatment of Temporomandibular Joint (TMJ) Disorder, Migraines, spinal stenosis, and obesity. His approach allows him to manage long-term pain and discomfort without the need for prescription pain relievers.

Pain management and TMJ pain, TMJ neuralgia, and headaches have all been treated with acupuncture for centuries. Acupuncture decreases pain feeling by stimulating the nerve directly, altering the quality of transmission along nerve cells, according to Western researchers. Acupuncture also increases the production of endorphins and neurotransmitters, which are naturally occurring chemicals that help the brain reduce and inhibit pain perception.

 

Temporomandibular Disorder Prognosis

Prognosis

Up to 45% of patients experience symptom resolution without any intervention, and the majority of patients respond well to conservative treatment. Refractory or chronic TMD affects a tiny percentage of people. Chronic TMD is not linked to any identified risk factors. However, new research has linked increased sympathetic tone to chronic TMJ pain.

 

Temporomandibular Disorder Complications

The typical triad of temporomandibular dysfunction comprises temporomandibular joint discomfort, restricted mandibular range of motion, and functional clicking. This can make it difficult for people to accomplish routine functions like eating, talking, or yawning, lowering their quality of life.

 

Conclusion

Although the majority of people experience symptoms of temporomandibular dysfunction, only a small percentage of people report their problems and seek treatment. Functional pain in the joint region and muscles, TMJ popping and crepitation, and difficulty and deviation when raising the mouth are the most typical symptoms. These symptoms normally go away on their own without the need for subsequent treatment. If not, conservative approaches are performed first, with positive outcomes in the vast majority of patients. The etiology of temporomandibular disorders is multifactorial, necessitating a multidisciplinary approach. Generally, family physicians and dentists are the first to be visited, and they can begin a noninvasive treatment for TMD. Stretching exercises, stress reduction, and behavioral treatment are all essential in managing such patients, thus a physiotherapist and a psychotherapist are also important parts of the healthcare team. Ultimately, if conservative treatment fails or if TMJ pain and dysfunction are severe, a maxillofacial referral should be made.