Temporomandibular joint disorder: Wikis

  

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Temporomandibular joint disorder
Classification and external resources

Temporomandibular joint
ICD-9 524.60
DiseasesDB 12934
MedlinePlus 001227
eMedicine neuro/366 radio/679 emerg/569
MeSH C05.500.607.221.897.897

Temporomandibular joint disorder (TMJD or TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporomandibular joint, which connects the mandible to the skull. The disorder and resultant dysfunction can result in significant pain and impairment. Because the disorder transcends the boundaries between several health-care disciplines — in particular, dentistry and neurology — there are a variety of treatment approaches.

The temporomandibular joint is susceptible to many of the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental anomalies, and neoplasia.

Contents

Signs and symptoms

Signs and symptoms of temporomandibular joint disorder vary in their presentation and can be very complex-but are often simple. On average the symptoms will involve more than one of the numerous TMJ components: muscles, nerves, tendons, ligaments, bones, connective tissue, and the teeth.[1] Ear pain associated with the swelling of proximal tissue is a symptom of temporomandibular joint disorder.

Symptoms associated with TMJ disorders may be:

  • Biting or chewing difficulty or discomfort
  • Clicking, popping, or grating sound when opening or closing the mouth
  • Dull, aching pain in the face
  • Earache
  • Headache
  • Jaw pain or tenderness of the jaw
  • Reduced ability to open or close the mouth

Temporomandibular joints

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 the proximity of the ear to the temporomandibular joint, TMJ pain can often be confused with ear pain.[2] The pain may be referred in around half of all patients and experienced as otalgia (earache).[3][4] Conversely, TMD is an important possible cause of secondary otalgia.[5] Treatment of TMD may then significantly reduce symptoms of otalgia and tinnitus,[6] as well as atypical facial pain.[7] 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.[8]

The dysfunction involved is most often in regards to the relationship between the condyle of the mandible and the disc.[9] 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.[citation needed]

Teeth

Disorders of the teeth can contribute to TMJ dysfunction.[10] Impaired tooth mobility and tooth loss can be caused by destruction of the supporting bone and by heavy forces being placed on teeth. The 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. Maybe the most important factor is the way the teeth meet together: the equilibration of forces of mastication and therefore the displacements of the condyle. Many report TMJ dysfunction after having their wisdom teeth extracted.

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 (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:

  1. Trauma
  2. Repetitive unconscious jaw movements called bruxing.
  3. Malalignment of the occlusal surfaces of the teeth due to dental defect or neglect.
  4. Jaw thrusting (causing unusual speech and chewing habits).
  5. Excessive gum chewing or nail biting.
  6. Size of foods eaten.
  7. Degenerative joint disease, such as osteoarthritis or organic degeneration of the articular surfaces, recurrent fibrous and/or bony ankylosis, developmental abnormality, or pathologic lesions within the TMJ
  8. Myofascial pain dysfunction syndrome
  9. Lack of overbite

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.[citation needed]

Pain relief

While conventional analgesic pain killers such as paracetamol (acetaminophen) or NSAIDs provide initial relief for some sufferers, the pain is often more neuralgic in nature, which often does not respond well to these drugs.[11]

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.[12][13]

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 habits 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. This method of treatment is often referred to as "splint therapy."

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.[14][15] 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.
  • Feldenkrais TMJ Program, uses a unique understanding of human neurology to reduce chronic tension in the jaw, face, neck, and upper back, and to reverse long-standing movement habits responsible for the original TMJ symptoms[16][17].
  • 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 (MORA) 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. According to an article on Quackwatch.org, MORA devices are considered the most widley used option although the scientific validity has not been proven.

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 (occlusal adjustment). This, too, is not a widely accepted practice and should be avoided as it is irreversible.
  • Mandibular repositioning splints which move the jaw, ligaments and muscles into a new position and myofunctional therapy
  • Reconstructive dentistry
  • Orthodontics
  • Arthrocentesis (joint irrigation)
  • Surgical repositoning of jaws to correct congenital 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 surgical treatments based on MRI and 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.[18] In some cases, this will reduce the inflammatory process.

Jaw dislocation

The jaw can dislocate if a person opens their mouth too wide, particularly when a person attempts to open the jaw widely in an effort to stretch the facial muscles i.e. to relieve tense facial muscles as the wisdom teeth develop and emerge. Dislocation can occur following a series of events if the jaw locks wide open and is unable to close by using the jaws muscles (unassisted) and without excessive force; cupping the palm of one hand under the chin and the other hands palm placed on top of the head, then using the arms muscles to force the jaw shut. As an immediate result of the dislocation, chronic pain can be experienced on both sides of the jaw, combined with an extreme headache and inability to concentrate.

Depending on the severity of the jaw's dislocation, pain relief using paracetamol (available over the counter at your local pharmacy) can assist to alleviate the initial chronic pain, however the effects of long-term use of paracetamol can decline as the condition deteriorates with continued use of the jaw through the day i.e. talking, eating, smoking, drinking, etc.

If a person's jaw locks open, never attempt to force it closed as described above, as this action can result in a dislocated jaw followed by chronic TMJD related pain.

Symptoms of a dislocated jaw

The symptoms can be numerous depending on the severity of the dislocation injury and how long the person is inflicted with the injury.

The immediate symptom can be a loud crunch noise occurring right up against your ear drum, except the sound is produced on the inside of your head and not only seems like you're breaking bones, but feels like it too. This is instantly followed by excruciating pain, particularly in the side where the dislocation occurred.

Short-term symptoms can range from mild to chronic headaches, muscle tension or pain in the face, jaw, neck, shoulders, back, arms and often in the legs.

Long-term symptoms can result in sleep deprivation, tiredness/lethargy, frustration, bursts of anger or short fuse, difficulty performing everyday tasks, depression, social issues relating to difficulty talking, hearing sensitivity (particularly to high pitched sounds), tinnitus and pain when seated associated with posture while at a computer and reading books from general pressure on the jaw and facial muscles when tilting head down or up.

You may also notice a sharp bolt of pain shoot down your body when you turn your head suddenly, this may be associated to the side of the jaw which is dislocated.

See also

The entry for "syndrome, Costen" in Dorland's Medical Dictionary is an all-encompassing definition of this symptom complex.

References

  • Okeson, Jeffrey P. (2003). Management of temporomandibular disorders and occlusion (5th ed.). St. Louis: Mosby. ISBN 0-323-01477-1. 

Footnotes

  1. ^ Okeson (2003), page 191.
  2. ^ Okeson (2003), page 233.
  3. ^ Tuz HH, Onder EM, Kisnisci RS (2003). "Prevalence of otologic complaints in patients with temporomandibular disorder". Am J Orthod Dentofacial Orthop 123 (6): 620–3. doi:10.1016/S0889-5406(03)00153-7. PMID 12806339. 
  4. ^ Ramírez LM, Sandoval GP, Ballesteros LE (2005). "Temporomandibular disorders: referred cranio-cervico-facial clinic". Med Oral Patol Oral Cir Bucal 10 Suppl 1: E18–26. PMID 15800464. http://www.medicinaoral.com/medoralfree01/v10Suppl1i/medoralv10suppl1ip18.pdf. 
  5. ^ Peroz I (2001). "[Otalgia and tinnitus in patients with craniomandibular dysfunctions]" (in German). HNO 49 (9): 713–8. PMID 11593771. 
  6. ^ Sobhy OA, Koutb AR, Abdel-Baki FA, Ali TM, El Raffa IZ, Khater AH (2004). "Evaluation of aural manifestations in temporo-mandibular joint dysfunction". Clin Otolaryngol Allied Sci 29 (4): 382–5. doi:10.1111/j.1365-2273.2004.00842.x. PMID 15270827. 
  7. ^ Quail G (2005). "Atypical facial pain--a diagnostic challenge" (PDF). Aust Fam Physician 34 (8): 641–5. PMID 16113700. http://www.racgp.org.au/afp/downloads/pdf/august2005/August_theme_quail2.pdf. 
  8. ^ Okeson (2003), page 234.
  9. ^ Okeson (2003), page 204.
  10. ^ Okeson (2003), page 227.
  11. ^ Vickers ER, Cousins MJ (2000). "Neuropathic orofacial pain. Part 2-Diagnostic procedures, treatment guidelines and case reports". Aust Endod J 26 (2): 53–63. PMID 11359283. 
  12. ^ Marbach JJ (1996). "Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment". Rheum. Dis. Clin. North Am. 22 (3): 477–98. doi:10.1016/S0889-857X(05)70283-0. PMID 8844909. 
  13. ^ Dionne RA (1997). "Pharmacologic treatments for temporomandibular disorders". Oral Surg Oral Med Oral Pathol Oral Radiol Endod 83 (1): 134–42. doi:10.1016/S1079-2104(97)90104-9. PMID 9007937. 
  14. ^ Lipton JA, Ship JA, Larach-Robinson D (1993). "Estimated prevalence and distribution of reported orofacial pain in the United States". J Am Dent Assoc 124 (10): 115–21. PMID 8409001. 
  15. ^ National Institutes of Health Technology Assessment Conference Statement. (1996). Management of temporomandibular disorders. Washington, D.C.: Government Printing Office.
  16. ^ http://www.tmj-lessons.com/"See also"
  17. ^ http://www.feldenkrais.com/
  18. ^ "Temporomandibular Disorders". The Cleveland Clinic. http://www.clevelandclinic.org/health/health-info/docs/3100/3152.asp. 

External links

TMJ replacement is undertaken as a last solution in end stage disease. It should be performed by a surgeon familiar with the procedure; there are a few in The UK. There is a British TMJ Surgeons' Society (qv) which can advise. Current thoughts are to use a custom prosthesis, the TMJ Concepts device (qv).








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