Temporomandibular joint disorder
30707
223732574
2008-07-05T14:29:22Z
Cyrus Grisham
373632
/* Precipitating factors */ reference tag was missing...
{{Infobox_Disease |
Name = Temporomandibular joint disorder |
Image = Gray309.png |
Caption = Temporomandibular joint |
DiseasesDB = 12934 |
ICD10 = {{ICD10|K|07|6|k|00}} |
ICD9 = {{ICD9|524.60}} |
ICDO = |
OMIM = |
MedlinePlus = 001227 |
eMedicineSubj = neuro |
eMedicineTopic = 366 |
eMedicine_mult = {{eMedicine2|radio|679}} {{eMedicine2|emerg|569}} |
MeshName = Temporomandibular+Joint+Dysfunction+Syndrome |
MeshNumber = C05.500.607.221.897.897 |
}}
'''Temporomandibular joint disorder''' ('''TMJD''', '''TMJ''' or '''TMD'''), or '''TMJ syndrome''', is an umbrella term covering [[Acute (medical)|acute]] or [[chronic (medicine)|chronic]] [[inflammation]] of the [[temporomandibular joint]], which connects the lower jaw to the [[skull]]. The disorder and resultant dysfunction can result in significant [[Pain|pain]] and impairment. Because the disorder transcends the boundaries between several health-care disciplines — in particular, [[dentistry]], [[neurology]], [[physical therapy]], and [[psychology]] — there are a variety of quite different treatment approaches.
The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including [[ankylosis]], [[arthritis]], trauma, [[dislocation (medicine)|dislocation]]s, developmental anomalies, and [[neoplasia]].
==Signs and symptoms==
Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex. Often the symptoms will involve more than one of the numerous TMJ components: [[muscle]]s, [[nerves]], [[tendons]], [[ligaments]], [[bone]]s, [[connective tissue]], and the [[teeth]].<ref>Okeson (2003), page 191.</ref>
Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.
===Muscles===
Disorders of the muscles of the temporomandibular joint are the most common complaints by TMD patients.<ref name="okeson 192">Okeson (2003), page 192.</ref> The two major observations concerning the muscles are pain and dysfunction. The dysfunction can present as [[trismus]] or limitation of jaw movement ranging from minor to severe. In milder cases, the only representation may be joint sound such as clicking or popping. These symptoms of TMD are often caused by overusage of the muscles of mastication. Common causes include chewing gum continuously, biting habits (fingernails and pencils), grinding habits, and clenching habits.
Most cases of TMJ, however, are not so simple. Deep-space infections with resulting trismus or neoplams about the joint may mimic TMJ dysfunction. Muscle pain can sometimes be associated with [[trigger point]]s in muscle tissue. These trigger points can be localized by digital palpation, both intraorally and extraorally.<ref name="okeson 198">Okeson (2003), page 198.</ref> This is known as [[Myofascial pain syndrome]].
Any dysfunction of the muscles may cause the teeth to occlude (bite) with each other incorrectly;<ref name="okeson 193">Okeson (2003), page 193.</ref>if teeth are traumatized by this, they may become sensitive, demonstrating one of the many interplays between muscle, joint, and tooth.
===Temporomandibular joints===
This is arguably the most complex set of joints in the human body. Unlike typical finger or vertebral junctions, each TMJ actually has two joints, which allow it to both rotate and to translate (slide). With use, it is common to see wear of both the bone and cartilage components of it. Clicking is common, as are popping motions and deviations in the movements of the joint. It is considered a TMJ disorder when pain is involved.
In a healthy joint, the surfaces in contact with one another (bone and cartilage) do not have any receptors to transmit the feeling of pain. The pain therefore originates from one of the surrounding soft tissues. When receptors from one of these areas are triggered, the pain causes a reflex to limit the mandible's movement. Furthermore, inflammation of the joints can cause constant pain, even without movement of the jaw.
Due to close proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain.<ref name="okeson 233">Okeson (2003), page 233.</ref> The pain may be [[referred pain|referred]] in around half of all patients and experienced as [[otalgia]] (earache).<ref name="pmid12806339">{{cite journal |author=Tuz HH, Onder EM, Kisnisci RS |title=Prevalence of otologic complaints in patients with temporomandibular disorder |journal=Am J Orthod Dentofacial Orthop |volume=123 |issue=6 |pages=620–3 |year=2003 |pmid=12806339 |doi=10.1016/S0889540603001537 |doi_brokendate=2008-06-25}}</ref><ref name="pmid15800464">{{cite journal |author=Ramírez LM, Sandoval GP, Ballesteros LE |title=Temporomandibular disorders: referred cranio-cervico-facial clinic |journal=Med Oral Patol Oral Cir Bucal |volume=10 Suppl 1 |issue= |pages=E18–26 |year=2005 |pmid=15800464 |doi= url=http://www.medicinaoral.com/medoralfree01/v10Suppl1i/medoralv10suppl1ip18.pdf |doi_brokendate=2008-06-25}}</ref> Conversely, TMD is an important possible cause of [[Otalgia#Secondary otalgia|secondary otalgia]].<ref name="pmid11593771">{{cite journal |author=Peroz I |title=[Otalgia and tinnitus in patients with craniomandibular dysfunctions] |language=German |journal=HNO |volume=49 |issue=9 |pages=713–8 |year=2001 |pmid=11593771 |doi=}}</ref> Treatment of TMD may then significantly reduce symptoms of otalgia and [[tinnitus]],<ref name="pmid15270827">{{cite journal |author=Sobhy OA, Koutb AR, Abdel-Baki FA, Ali TM, El Raffa IZ, Khater AH |title=Evaluation of aural manifestations in temporo-mandibular joint dysfunction |journal=Clin Otolaryngol Allied Sci |volume=29 |issue=4 |pages=382–5 |year=2004 |pmid=15270827 |doi=10.1111/j.1365-2273.2004.00842.x}}</ref> as well as atypical facial pain.<ref name="pmid16113700">{{cite journal |author=Quail G |title=Atypical facial pain--a diagnostic challenge |journal=Aust Fam Physician |volume=34 |issue=8 |pages=641–5 |year=2005 |pmid=16113700 |doi= | url=http://www.racgp.org.au/afp/downloads/pdf/august2005/August_theme_quail2.pdf | format=PDF}}</ref> Despite some of these findings, some researchers question whether TMD therapy can reduce symptoms in the ear, and there is currently an ongoing debate to settle the controversy.<ref name="okeson 234">Okeson (2003), page 234.</ref>
The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc.<ref name="okeson 204">Okeson (2003), page 204.</ref> The sounds produced by this dysfunction are usually described as a "click" or a "pop" when a single sound is heard and as "crepitation" or "crepitus" when there are multiple, rough sounds.
===Teeth===
Disorders of the teeth can contribute to TMJ dysfunction.<ref name="okeson 227">Okeson (2003), page 227.</ref> Tooth mobility and [[tooth loss]] can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. Movement of the teeth affects how they contact one another when the mouth closes, and the overall relationship between the teeth, muscles, and joints can be altered. Pulpitis, inflammation of the dental pulp, is another symptom that may result from excessive surface erosion.
==Precipitating factors==
There are many external factors that place undue strain on the TMJ. These include but are not limited to the following:
Over-opening the jaw beyond its range for the individual or unusually aggressive or repetitive sliding of the jaw sideways ([[Anatomical terms of location|laterally]]) or forward (protrusive). These movements may also be due to parafunctional habits or a malalignment of the jaw or dentition. This may be due to:
# Modification of the occlusal surfaces of the teeth through dental neglect or accidental trauma.
# Speech habits resulting in jaw thrusting.
# Excessive gum chewing or nail biting.
# Excessive jaw movements associated with exercise.
# Repetitive unconscious jaw movements associated with [[bruxism|bruxing]].
# Size of foods eaten.
Some recent studies have demonstrated a statistical relation between bipolar disorder and temporomandibular joint disorder<ref>AJ Giannini, AE Slaby, JP Gianetti,MS Darosky.Correlates on physical examination of bipolar disorder. Turkish Journal of Biological and Medical Research.2(1):23-30,1991.</ref>
==Treatment==
===Restoration of the occlusal surfaces of the teeth===
If the occlusal surfaces of the teeth or the supporting structures have been damaged due to dental neglect, periodontal diseases or trauma, the proper occlusion should be restored.
===Pain relief===
While conventional [[analgesic]] pain killers such as [[paracetamol]] (acetaminophen) or [[NSAIDs]] provide initial relief for some sufferers, the pain is often more [[neuralgia|neuralgic]] in nature, which often does not respond well to these drugs.<ref name="pmid11359283">{{cite journal |author=Vickers ER, Cousins MJ |title=Neuropathic orofacial pain. Part 2-Diagnostic procedures, treatment guidelines and case reports |journal=Aust Endod J |volume=26 |issue=2 |pages=53–63 |year=2000 |pmid=11359283 |doi=}}</ref><!-- this ref supports this with "Medication rationalisation utilises first-line antineuropathic drugs including tricyclic antidepressants " rather than simple analgesics -->
An alternative approach is for pain modification, for which [[off-label use]] of low-doses of [[Tricyclic antidepressant]] that have [[anti-muscarinic]] properties (e.g. [[Amitriptyline]] or the less sedative [[Nortriptyline]]) generally prove more effective.<ref name="pmid8844909">{{cite journal |author=Marbach JJ |title=Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment |journal=Rheum. Dis. Clin. North Am. |volume=22 |issue=3 |pages=477–98 |year=1996 |pmid=8844909| doi = 10.1016/S0889-857X(05)70283-0 <!--Retrieved from CrossRef by DOI bot-->}}</ref><ref name="pmid9007937">{{cite journal |author=Dionne RA |title=Pharmacologic treatments for temporomandibular disorders |journal=Oral Surg Oral Med Oral Pathol Oral Radiol Endod |volume=83 |issue=1 |pages=134–42 |year=1997 |pmid=9007937| doi = 10.1016/S1079-2104(97)90104-9 <!--Retrieved from CrossRef by DOI bot-->}}</ref><!-- also eMedicine http://www.emedicine.com/neuro/topic366.htm as given in infobox -->
===Long-term approach===
It is suggested that before the attending dentist commences any plan or approach utilizing medications or surgery, a thorough search for inciting para-functional jaw habits must be performed. Correction of any discrepancies from normal can then be the primary goal.
An approach to eliminating [[para-functional habit]]s involves the taking of a detailed history and careful physical examination. The medical history should be designed to reveal duration of illness and symptoms, previous treatment and effects, contributing medical findings, history of facial trauma, and a search for habits that may have produced or enhanced symptoms. Particular attention should be directed in identifying perverse jaw habits, such as clenching or teeth grinding, lip or cheek biting, or positioning of the lower jaw in an edge-to-edge bite. All of the above strain the muscles of mastication (chewing) and results in jaw pain. Palpation of these muscles will cause a painful response.
Treatment is oriented to eliminating oral habits, physical therapy to the masticatory muscles, and alleviating bad posture of the head and neck. A flat-plane full-coverage [[oral appliance]], e.g. a non-repositioning stabilization splint, often is helpful to control [[bruxism]] and take stress off the temporomandibular joint, although some individuals may bite harder on it, resulting in a worsening of their conditions. The anterior splint, with contact at the front teeth only, may then prove helpful.
According to the National Institute of Dental and Craniofacial Research (NIDCR) of the National Institutes of Health (NIH), TMJ treatments should be reversible whenever possible. That means that the treatment should not cause permanent changes to the jaw or teeth.<ref name="pmid8409001">{{cite journal |author=Lipton JA, Ship JA, Larach-Robinson D |title=Estimated prevalence and distribution of reported orofacial pain in the United States |journal=J Am Dent Assoc |volume=124 |issue=10 |pages=115–21 |year=1993 |pmid=8409001 |doi=}}</ref><ref name="NIH1996">National Institutes of Health Technology Assessment Conference Statement. (1996). ''Management of temporomandibular disorders.'' Washington, D.C.: Government Printing Office.</ref>
Examples of reversible treatments are:
*Over-the-counter pain medications, used according to manufacturers’ instructions.
* Prescription medications prescribed by a healthcare provider.
* Gentle jaw stretching and relaxation exercises you can do at home. Your healthcare provider can recommend exercises for your particular condition, if appropriate.
* Stabilization splint (biteplate, nightguard) is the most widely used treatment for TMJ and jaw muscle problems; however, the actual effectiveness of these splints is unclear. If an oral splint is recommended, it should be used only for a short time and should not cause permanent changes in the bite. If a splint causes or increases pain, stop using it and tell your healthcare provider. Avoid using over-the-counter mouthguards for TMJ treatment. If a splint is not properly fitted, the teeth may shift and worsen the condition.
* Mandibular Repositioning Devices can be worn for a short time to help alleviate symptoms related to painful clicking when opening the mouth wide, but 24-hour wear for the long term may lead to changes in the position of the teeth that can complicate treatment. A typical long-term permanent treatment (if the device is proven to work especially well for the situation) would be to convert the device to a flat-plane bite plate fully covering either the upper or lower teeth and to be used only at night.
What may be concluded is that there are various treatment modalities which a well-trained experienced dentist may employ to relieve symptoms and improve joint function. They include:
* Manual adjustment of the bite by grinding the teeth
* Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
* Reconstructive dentistry
* Orthodontics
* Arthocentisis
* Surgical repositoning of jaws to correct congential jaw malformations such as prognathism and retrognathia
* Replacement of the jaw joint(s) or disc(s) with TMJ implants (This should be considered only as a treatment of last resort.)
Attempts in the last decade to develop [[Surgery|surgical treatment]]s based on [[MRI]] and [[Computed axial tomography|CAT]] scans now receive less attention. These techniques are reserved for the most recalcitrant cases where other [[therapeutic modalities]] have changed. Exercise protocols, habit control, and splinting should be the first line of approach, leaving [[oral surgery]] as a last resort. Certainly a focus on other possible causes of facial pain and jaw immobility and dysfunction should be the initial consideration of the examining oral-facial pain specialist, oral surgeon or health professional.
One option for oral surgery, is to manipulate the jaw under general anaesthetic and wash out the joint with a saline and anti-inflammatory solution in a procedure known as [[arthrocentesis]].<ref name="clevelandclinic">{{cite web |title=Temporomandibular Disorders |url=http://www.clevelandclinic.org/health/health-info/docs/3100/3152.asp?index=10960&src=news |publisher=The Cleveland Clinic}}</ref> In some cases, this will reduce the inflammatory process.
==See also==
*[[Bruxism]]
==References==
* {{cite book |last = Okeson | first = Jeffrey P. |title=Management of temporomandibular disorders and occlusion |publisher=Mosby |location=St. Louis |year=2003 |edition=5th edition |pages= |isbn=0-323-01477-1 |oclc= |doi=}}
==Footnotes==
{{Reflist|2}}
==External links==
*[http://www.tmj.org The TMJ Association] - a national non-profit association.
*[http://my.webmd.com/content/article/66/79637.htm WebMD] - Includes some basic treatments
*{{GPnotebook|-194314226|Temporomandibular joint syndrome}}
*{{FPnotebook|DEN/Jaw/TmprmndblrJntDs|Temporomandibular Joint Disease}}
*[http://www.tmj-orthodontics.com Temporomandibular Joint Disorder] - CMD Orthodontics / TMJ-Orthodontics
*{{MedlinePlusOverview|temporomandibularjointdysfunction}}
*{{MerckHome|08|116|a}}
* {{cite web | title=The Temporomandibular Joint (TMJ) | url=http://www.aaoms.org/tmj.php | publisher=American Association of Oral and Maxillofacial Surgeons | year=2005 | accessdate=2007-03-04}}
*[http://www.fda.gov/cdrh/consumer/tmjupdate.html FDA CDRH Consumer Information Update on TMJ Implants] - Center for Devices and Radiological Health Consumer Informational Update on TMJ Implants
* [http://www.galiffasyndrome.com Health & Sleeping positions] Galiffa
{{dentistry}}
{{Oral pathology}}
[[Category:Pain]]
[[Category:Dental disorders]]
[[Category:Musculoskeletal disorders]]
[[Category:Medical terms]]
[[de:Kraniomandibuläre Dysfunktion]]
[[fr:Syndrome algo-dysfonctionnel de l'appareil manducateur]]
[[it:Articolazione temporo-mandibolare]]
[[ja:顎関節症]]
[[pt:Disfunção da articulação temporomandibular]]