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temporomandibular joint (TMJ) syndrome

A syndrome used to describe a collection of symptoms related to temporomandibular joint (TMJ) dysfunction. The presence of only early manifestations of TMJ syndrome (i.e. pain & tenderness without intra-articular manifestations) is referred to as myofascial pain dysfunction (MPD) syndrome. Etiology: 1) inflammatory & degenerative joint disease a) rheumatoid arthritis b) osteoarthritis c) gout 2) infectious arthritis 3) tumors of joint structures & surrounding area 4) developmental joint anomalies 5) risk factors a) fatigue & spasm of the regional muscles 1] stress & tension 2] parafunctional habits a] clenching of teeth b] excessive chewing of gum b) malocclusion of teeth, missing teeth & malfitting dentures c) excessive & prolonged opening of mouth Epidemiology: 1) most common in Caucasian females in 2nd to 4th decades 2) less than 1/2 individuals with clinical evidence of TMJ syndrome are aware of the problem Pathology: 1) persistent malfunction of the TMJ gradually causes degeneration of the intra-articular disc. 2) displacement, deformity & eventually perforation of the disc occur 3) meniscitis, synovitis & capsulitis occur 4) bone to bone contact eventually occur 5) pain, tenderness, spasm in regional muscles & noises in the joint & limited mandibular mobility result Clinical manifestations: 1) early manifestations a) pain in & around the TMJ - dull to sharp pain - aggravated by jaw movement - chewing almost always worsens pain [3] - radiation pain to ear, eye, head & face b) tenderness/spasm of the muscles of mastication & head & neck c) anxiety 2) late manifestations a) joint noises - clicking, grinding & grating sounds b) limited mandibular movement - inflammation - disc displacement Special laboratory: 1) arthroscopy of TMJ 2) injection of local anesthetic into joint to confirm source of pain Radiology: 1) radiographs usually not helpful [3] - indications - dental disease suspected - failure to respond to conservative therapy [3] 2) TMJ radiographs 3) computed tomography may be better for viewing early changes 4) magnetic resonance imaging (MRI) a) imaging modality of choice - lack of response to conservative management - non-dental structural pathology suspected [3] b) soft tissue pathology in the disc, synovium & capsule 5) TMJ arthrography - disc deformity, abnormal motion, perforation Differential diagnosis: 1) otitis media 2) neuralgia 3) sinusitis 4) arthritis a) rheumatoid arthritis b) osteoarthritis c) gout d) psoriatic arthritis e) septic arthritis 5) tooth pain 6) parotid gland pathology 7) tumors a) brain tumor b) head & neck cancer 8) tetanus 9) other muscular &/or neurologic conditions Management: 1) initial therapy a) mandibular rest b) soft diet c) local heat d) change habits/behavior e) jaw therapeutic exercises f) pharmaceutical agents - non-steroidal anti-inflammatory drugs (NSAIDs) of unproven value - avoid antidepressants - avoid fluoxetine & paroxetine - they may be associated with bruxism, exacerbating TMJ syndrome [3] - anxiolytic agents - avoid narcotics because of prolonged course of TMJ syndrome 2) long term management a) referral to TMJ specialist for behavioral modification & stress reduction - cognitive behavioral therapy reduces pain, depression & interference with activities [3] - biofeedback may be useful - hypnosis - psychologic counseling b) jaw appliances of uncertain benefit - occlusal bite guards - occlusal repositioning appliances c) surgery - referral to oral & maxillofacial surgeon - arthroscopic surgery in appropriate circumstances d) pharmaceutical agents - carbamazepine - neurontin - dilantin e) prolotherapy with hypertonic 20% dextrose + lidocaine [6] - monthly injections into TMJ

Related

myofascial pain dysfunction (MPD) syndrome temporomandibular joint (TMJ)

General

joint disease; articular disease; arthropathy syndrome chronic musculoskeletal disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 772-73
  2. Scrivani SJ, Keith DA, Kaban LB. Temporomandibular disorders. N Engl J Med. 2008 Dec 18;359(25):2693-705 PMID: 19092154
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, American College of Physicians, Philadelphia 2009, 2012
  4. Mujakperuo HR, Watson M, Morrison R, Macfarlane TV. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD004715 PMID: 20927737
  5. NIH Press Release. Feb 3, 2014 First evidence-based diagnostic criteria published for temporomandibular disorders. http://www.nih.gov/news/health/feb2014/nidcr-03.htm
  6. Louw WF et al. Treatment of temporomandibular dysfunction with hypertonic dextrose injection (prolotherapy): A randomized controlled trial with long-term partial crossover. Mayo Clin Proc 2019 May; 94:820. PMID: 30878157 Free full text
  7. National Institute of Dental and Craniofacial Research TMJ (Temporomandibular Joint & Muscle Disorders) https://www.nidcr.nih.gov/health-info/tmj