AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

TMJ, or temporal mandibular joint, is the synovial joint that connects the jaw to the skull. These two joints are located just in front of each ear. Each joint is composed of the condyle of the mandible, an articulating disk, and the articular tubercle of the temporal bone. The movements allowed are side to side, up and down, as well as protrusion and retrusion. This complicated joint along with its attached muscles, allows movements needed for speaking, chewing, and making facial expressions.

Uyanik et al identifies 3 distinct causes of pain at the TMJ, which collectively fall under the broader term of TMJ syndrome.

• Myofascial pain dysfunction (MPD) syndrome, pain at the TMJ due to various causes of increased muscle tension and spasm. It is believed that MPD syndrome is a physical manifestation of psychological stress. No primary disorder of the joint itself is present. Pain is secondary to events such as nocturnal jaw clenching and teeth grinding. Treatment is focused on behavioral modification as opposed to joint repair.
• Internal derangement (ID), where the problem lies within the joint itself, most commonly with the position of the articulating disc
• Degenerative joint disease, where arthritic changes result in degeneration of the articulating surfaces

Pathophysiology

The pathophysiology is not entirely understood, but it is believed that TMJ dysfunction syndrome arises from both local insults and systemic disorders. Local problems frequently arise from articular disc displacement and hereditary conditions affecting the structures of the joint itself, such as hypoplastic mandibular condyles.

The TMJs also can be affected by conditions such as rheumatoid arthritis, osteoarthritis, and diseases of the articular disks. In addition, hypermobile TMJs, nocturnal jaw clenching, nocturnal teeth grinding, jaw clenching due to psychosocial stresses, and local trauma also play a significant role.

As described by Hegde et al, a strong understanding of how the trigeminal nerve innervates the TMJ and surrounding structures explains the pain and referred pain patterns of TMJ disorders. Irritation of the mandibular branch (V3) of the trigeminal nerve results in pain locally at the TMJ and also to other areas of V3 sensory innervation, which include the ipsilateral skin, teeth, side of the head, and scalp.

Frequency

United States

Currently, an estimated 10 million people have TMJ disorders, and roughly 25% of the population have symptoms at some point in their lives.

Mortality/Morbidity

The morbidity of the disorder is related to significant pain on movement of the jaw. While some patients' symptoms may resolve within weeks, others may have chronic symptoms that persist even with extensive therapy.

One study by Rammelsberg et al followed 235 patients over 5 years. In this study, roughly one third of patients had completely resolved pain, one third had continuous pain over the 5 years, and one third had recurrent episodes with periods of remission.

Race

No apparent association with race exists.

Sex

Female-to-male ratio is roughly 4:1.

Age

• Greatest incidence is in adults aged 20-40 years.
• TMJ syndrome is found infrequently in the pediatric population.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Symptoms
• • Chronic pain in the muscles of mastication described as a dull ache, typically unilateral
  • Pain may radiate to the ear and jaw, and is worsened with chewing
  • Locking of the jaw when attempting to open the mouth
  • Ear clicking or popping, usually when displacement of the articular disk is present.
  • Headache and/or neck ache
  • A bite that feels uncomfortable or different from usual
  • Neck, shoulder, and back pain
  • Bruxism, teeth clenching
  • Increasing pain over the course of the day
  • History of jaw and/or facial trauma

Physical

• Limitation of jaw opening (normal range is at least 40 mm as measured from lower to upper anterior teeth)
• Palpable spasm of facial muscles (masseter and internal pterygoid muscles)
• Unilateral facial swelling
• Clicking or popping in the TMJ
• Tenderness to palpation of the TMJ via the external auditory meatus
• Crepitus over joint (in advanced disease)
• Lateral deviation of mandible

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Parotid gland disorders
Lesions of the oropharyngeal cavity
Tick-borne diseases
Lyme disease

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No laboratory studies are specifically indicated to rule in TMJ syndrome; however, appropriate laboratory samples may be drawn to help rule out other disorders.
• • Complete blood count (CBC), if infection is suspected
  • Calcium, phosphate, or alkaline phosphatase, for possible bone disease
  • Uric acid if gout is suspected
  • Serum creatine and creatine phosphokinase, indicators of muscle disease
  • Erythrocyte sedimentation rate if temporal arteritis is suspected and rheumatoid factor if rheumatoid arthritis is suspected

Imaging Studies

• Imaging studies generally are not indicated in the ED, unless a fracture is suspected.
• • Panorex may show a fracture, evidence of osteoarthritis, or displacement of the articular disk. Ahn et al demonstrated that Panorex films can also be affective in evaluating patients with internal derangement of the TMJ.
  • Plain radiographs may demonstrate resting and hinge movement of the TMJ.
  • CT scan may reveal greater detail of bones than radiographs alone.
  • MRI is inferior to Panorex and CT for bony pathology but is the best test when looking for disk pathology. If disk displacement is suspected, MRI is the test of choice in addition to CT and plain films.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Emergency Department Care

• Analgesics - Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Muscle relaxants - Benzodiazepines
• Moist heat and massage of masticatory muscles

Consultations

Provide outpatient follow-up care with ear, nose, and throat (ENT) specialist or oral surgeon. However, if intractable pain is present, more urgent consultation is necessary.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

NSAIDs and benzodiazepines are the mainstays of treatment for TMJ syndrome within the ED. Patients eventually may require tricyclics, opioids, muscle relaxants, or steroid (intraarticular) therapy for protracted pain syndromes.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Most commonly used for relief of mild to moderate pain. Although effects of NSAIDs in treatment of pain tend to be patient specific, ibuprofen usually is the DOC for initial therapy. Other options include naproxen, flurbiprofen, mefenamic acid, ketoprofen, indomethacin, and piroxicam.

Drug Name	Naproxen (Aleve, Anaprox, Naprosyn)
Description	Used for relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult Dose	250-500 mg PO bid; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric Dose	<2 years: Not established >2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; PT may increase with coadministration of anticoagulants; monitor PT and bleeding; coadministration with phenytoin may increase serum phenytoin levels, resulting in an increase in pharmacologic and toxic effects of phenytoin
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present

Drug Name	Flurbiprofen (Ansaid)
Description	Analgesic, antipyretic, and anti-inflammatory effects; may inhibit cyclooxygenase enzyme, causing inhibition of prostaglandin biosynthesis that in turn may result in analgesic and anti-inflammatory activities.
Adult Dose	200-300 mg/d PO divided bid/qid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; epithelial herpes simplex keratitis
Interactions	Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; coadministration with anticoagulants may prolong PT; monitor PT and bleeding; nephrotoxicity of both cyclosporine and flurbiprofen may be increased; coadministration with phenytoin may increase serum phenytoin levels, resulting in increase in pharmacologic and toxic effects of phenytoin
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present

Drug Name	Ketoprofen (Oruvail, Orudis, Actron)
Description	Used for relief of mild to moderate pain and inflammation; administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease; doses >75 mg do not increase therapeutic effects; administer high doses with caution and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	<3 months: Not established 3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; GI disease; cardiovascular disease; renal or hepatic impairment; patients receiving anticoagulants
Interactions	Probenecid and lithium may increase concentrations and possibly toxicity of NSAIDs; effect of loop diuretics may decrease with coadministration; PT may increase when ketoprofen is coadministered with anticoagulants; monitor for bleeding; coadministration with phenytoin may increase serum phenytoin levels, resulting in increase in pharmacologic and toxic effects of phenytoin
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; caution in congestive heart failure, hypertension, and decreased hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy; severe GI tract ulceration and bleeding can occur; monitor patients closely when administering prolonged treatments; NSAIDs can inhibit platelet aggregation, but at a lower degree than that observed with aspirin; low WBC counts can occur but usually return to normal as therapy continues; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present

Drug Name	Mefenamic acid (Ponstel)
Description	Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose	500 mg PO initially followed by 250 mg q4h prn
Pediatric Dose	<12 years: Not established >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Category D in third trimester of pregnancy; may have adverse effects in fetus; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Drug Name	Indomethacin (Indocin, Indochron E-R)
Description	Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation; inhibits prostaglandin synthesis.
Adult Dose	25-50 mg PO bid/tid 75 mg SR PO bid; not to exceed 200 mg/d
Pediatric Dose	1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Contraindications	Documented hypersensitivity; GI bleeding or renal insufficiency
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)

Drug Name	Piroxicam (Feldene)
Description	Decreases activity of cyclooxygenase, which in turn inhibits prostaglandin synthesis; effects decrease formation of inflammatory mediators.
Adult Dose	10-20 mg/d PO qd
Pediatric Dose	0.2-0.3 mg/kg/d PO qd; not to exceed 15 mg/d
Contraindications	Documented hypersensitivity; active GI bleeding
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)

Drug Category: Benzodiazepines

Used for muscle relaxant properties but relatively contraindicated in pediatric patients because of sedating properties; appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters by binding to specific receptor sites.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• Outpatient therapies should begin conservative and become more invasive when other options have been exhausted. Along with NSAIDs and muscle relaxants, initial treatment should also include behavior and diet modification.
• Patients should eat a soft diet, and avoid habits such as excessive gum chewing. Warm and cold compresses should be used at night along with gentle massage of the TMJ area. Patients need to avoid jaw clenching and teeth grinding if possible.
• Bite plates can be used to keep the jaw more properly aligned. They also help limit nocturnal bruxism and teeth grinding. Some patients also find benefit from ultrasonic therapy. This provides deep heat to the area of tenderness and may alleviate some patients symptoms. High-voltage electrogalvanic stimulation is sometimes used to reduce muscle spasms. Some practitioners perform prylotherapy, where combinations of dextrose, lidocaine, and Sarapin are injected into the TMJs. Injections of steroids may accompany local anesthetic injection as well.
• If failure of these more conservative treatments occurs, operative repair may be considered. Operative repair can range from arthroscopic procedures that can wash out the joint and allow for small repairs to open procedures. Open procedures can utilize jaw implants and synthetic articular disks. Surgery, however, is far from a cure. Friction et al demonstrated in a long-term study in which patients with synthetic implants did not have improved outcome over patients with nonimplant surgical repair or patients with nonsurgical rehabilitation. This was determined by looking at subjective and objective measures of symptom severity and functional deficits.

In/Out Patient Meds

• NSAIDs are the first line of treatment for TMJ pain.
• Prescribe benzodiazepines for significant muscle pain or spasm.
• Cyclobenzaprine may be prescribed in patients unable to tolerate benzodiazepines. Clinical efficacy of this drug for TMJ syndrome has not been studied.

Complications

• Alterations in dentition
• Chronic facial pain
• Malocclusion

Prognosis

• Prognosis is improved with early diagnosis.
• TMJ disorders often progress to a chronic state.
• Some cases may be self-limiting.
• Patients with ear symptomatology tend to have a prolonged course of illness.

Patient Education

• Control pain as needed.
• Instruct patient to apply moist heat to affected area for no longer than 15 minutes per application.
• Educate patient about bruxism and the need to avoid clenching and grinding teeth.
• Suggest that stress can play a major role in illness.
• • Teach stress reduction strategies.
  • Provide behavior modification and counseling.
• Prescribe soft diet for patients with chewing pain, and advise them to chew more slowly and take smaller bites.
• Instruct patient in jaw-opening exercises.
• For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Temporomandibular Joint (TMJ) Syndrome.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to make appropriate diagnosis (ie, migraine or dental disease is an incorrect diagnosis), leading to delayed treatment of TMJ syndrome
• Failure to properly estimate patient's level of pain; ineffective pain management may lead to increased morbidity

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ahn SJ, Kim TW, Lee DY. Evaluation of internal derangement of the temporomandibular joint by panoramic radiographs compared with magnetic resonance imaging. Am J Orthod Dentofacial Orthop. Apr 2006;129(4):479-85. [Medline].
• Dierks EJ. Temporomandibular disorders and facial pain syndromes. Otolaryngology. 1991;1:849-64.
• Dionne RA. Pharmacologic treatments for temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jan 1997;83(1):134-42. [Medline].
• Ficarra BJ, Nassif NJ. Temporomandibular joint syndrome: diagnostician''s dilemma--a review. J Med. 1991;22(2):97-121. [Medline].
• Fricton JR, Look JO, Schiffman E, Swift J. Long-term study of temporomandibular joint surgery with alloplastic implants compared with nonimplant surgery and nonsurgical rehabilitation for painful temporomandibular joint disc displacement. J Oral Maxillofac Surg. Dec 2002;60(12):1400-11; discussion 1411-2. [Medline].
• Greenberg SA, Jacobs JS, Bessette RW. Temporomandibular joint dysfunction: evaluation and treatment. Clin Plast Surg. Oct 1989;16(4):707-24. [Medline].
• Hegde V. A review of the disorders of the temporomandibular joint. J Indian Prosthodont Soc. 2005;5:56-61.
• Laskin DM. Etiology of the pain-dysfunction syndrome. J Am Dent Assoc. Jul 1969;79(1):147-53. [Medline].
• Laskin DM. Temporomandibular joint disorders. Arch Otolaryngol Head Neck Surg. 1993;2:1443-50.
• Mew JR. The aetiology of temporomandibular disorders: a philosophical overview. Eur J Orthod. Jun 1997;19(3):249-58. [Medline].
• Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th ed. 1999.
• Okeson JP, de Kanter RJ. Temporomandibular disorders in the medical practice. J Fam Pract. Oct 1996;43(4):347-56. [Medline].
• Rammelsberg P, LeResche L, Dworkin S. Longitudinal outcome of temporomandibular disorders: a 5-year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 2003;17(1):9-20. [Medline].
• Uyanik JM, Murphy E. Evaluation and management of TMDs, Part 1. History, epidemiology, classification, anatomy, and patient evaluation. Dent Today. Oct 2003;22(10):140-5. [Medline].
• Weinerger BW. Introduction to the History of Dentistry. St. Louis: CV Mosby Co;1948:390.

Article Last Updated: Dec 6, 2006