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Diagnosis, treatment and management of TMJ disorders

Article  in  Dental Nursing · December 2011

DOI: 10.12968/denn.2011.7.12.682

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 Clinical

Diagnosis, treatment and

management of TMJ disorders
Temporomandibular joint disorders, commonly called TMJ, are a group of conditions that cause pain
and dysfunction in the jaw joint and the muscles that control jaw movement. It is important that dental
nurses can identify these patients and provide them with information and support about their condition

T
emporomandibular joint

SCIENCE PHOTO LIBRARY

disorders is a collective
term embracing a number
of clinical problems that
involve the muscles of mastication and
the temporomandibular joint (TMJ),
and its associated structures (Okeson,
1996). Pain is the defining feature of
TMJ disorders and is the most common
reason why patients seek care; other
complaints may involve joint noises or
limited or asymmetrical jaw movement
(Dimitroulis, 1998).
The aetiology of a large number of
TMJ disorders is still not clear, although
the literature suggests parafunctional
activity, or habitual movements such
as bruxism or tooth clenching. Other
factors include hormonal influences,
stress, previous trauma to the joint,
the shape of the TMJ and degenerative Figure 1. A dissection of the temporomandibular joint
change within the joint (Rigon et al,
2011). It is thought that the prevalence (Shi et al, 2003) and in women (Luther et the external auditory meatus or the bony
of TMJ problems may be up to 76% of al, 2010). Research shows that quality of auditory canal. Lateral to the joint lies the
the population, being more prevalent in life can be significantly impaired among zygomatic arch and medial lies the styloid
patients between 20 and 40 years of age patients suffering from TMJ dysfunction process.
(Dahlstrom and Carlsson, 2010). This The TMJ is a synovial joint capable
highlights the importance of recognizing, of gliding, hinging, sliding and slight
Graham Cope is honorary senior diagnosing and treating patients with rotation. A feature of this joint is the
research fellow, Department of these problems as effectively as possible. meniscus, or ‘articular disc’, which lies
Medicine and Dentistry, University between the condylar head and glenoid
of Birmingham; and Anwen Cope Anatomy of the TMJ fossa. This acts as a shock absorber for
is postgraduate researcher, School The temporomandibular joint (Figure 1) the joint and allows smooth movement
of Medicine, Cardiff University, is formed by the articulation between the of the lower jaw. The disc is composed of
Wales condyle of the mandible and the glenoid fibrocartilagenous tissue and is separated
fossa, a concavity in the temporal bone of into three function areas: the anterior
Email: [email protected] the skull. At the front of the glenoid fossa band; the intermediate zone and the
lies the articular eminence and at the back posterior band. The disc is attached

14  Dental Nursing December 2011 Vol 7 No 12

 Clinical

anteriorly to the superior head of the

lateral pterygoid muscle and merges Box 1. Muscles involved in jaw movements
peripherally with the joint capsule and
then posteriorly it is attached to the Actions Muscles
capsule by a bilaminar zone (Berkovitz Depression (open mouth) Lateral pterygoid, suprahyoid and infrahyoid
et al, 2011). The capsule is a fibrous Elevation (close mouth) Temporalis, masseter, medial pterygoid
membrane that surrounds the joint and
attaches to the articular eminence, the Protrusion (Sticking chin forwards) Masseter, lateral pterygoid, medial pterygoid
articular disc and the neck of the condyle. Retrusion (Moving chin backwards) Temporalis and masseter
The fibrous capsule is thickened laterally
Lateral Movements (side-to-side grinding) Temporalis, pterygoid muscles and masseter
to form the lateral (temporomandibular)
ligament, which reinforces the lateral
part of the capsule. The joint is also Box 2. Symptoms associated with TMJ disorders
supported by the stylomandibular and
sphenomandibular ligaments. • Jaw pain (either at rest or when eating)
The movements of the TMJ are mainly
• Headache (may be worse in the morning)
controlled by the muscles of mastication:
temporalis, masseter, lateral and medial • Limitation of jaw opening
pterygoids (Box  1). Opening the mouth • Locking of the jaw
requires two distinct movements: first
• Earache
is the rotation of the condylar head
anteriorly within the fossa. The second • ‘Clicking’, ‘popping’ or ‘grinding’ sounds of the TMJ
is a translational slide where the condyle • Dull ache in face or neck
and the articular disc move anteriorly
down the articular eminence of the tomography (CT) or magnetic resonance can also occur. Among individuals with
temporal bone. imaging (MRI) may also be undertaken. TMJ disorders, around 11% have symptoms
of TMJ-osteoarthritis (Mejersjö and
Problems arising from Myofacial pain dysfunction Hollender, 1984) and a significant number
the TMJ syndrome of these will have had some previous
Diagnosis Myofacial pain dysfunction syndrome is trauma to the joint. TMJ-osteoarthritis
Some of the presenting symptoms of the most common temporomandibular is characterized by breakdown of the
TMJ problems are presented in Box 2. disorder. This is one of many names articular cartilage, architectural changes in
It is important to record in a patient’s for this condition including: facial the bone and degeneration of the synovial
clinical history: description and arthromyalgia, TMJ dysfunction tissues. The most common symptom of
duration of pain or other symptoms, syndrome, pain dysfunction syndrome TMJ-osteoarthritis is painful joints, while
any exacerbating or relieving factors and craniomandibular dysfunction (Gray other symptoms include limitation of jaw
and any previous interventions, either et al, 1994). Patients usually, although opening, coarse grinding noises and a
physical or pharmacological. Recently, not always, present with a dull, unilateral previous history of clicking. Characteristic
a novel questionnaire for screening for pain spreading out from the TMJ. The appearance of osteoarthritis of the TMJ
TMJ disorders was developed. This was pain is likely to be reduced by heat on OPGs include flattening and beaking
to identify patients who require further application and rest, but exacerbated by of the condylar head with evidence of
clinical evaluation and to aid in the eating, chewing gum or clenching the osteophyte formation, while MRIs may
diagnostic process (Gonzalez et al, 2011). teeth together. Typical triggers include show a more detailed picture of the
On examination, the dentist should stress, fatigue, depression and bruxism. destruction and sclerosis occurring within
note noises arising from the joint the joint (Bertram et al, 2001).
area, deviation of mandible on either Degenerative disease
opening or closing of the jaw, tenderness The TMJ is susceptible to all conditions Disc displacement
of musculature of mastication and the that affect other joints. The most common Disc displacement, as the name suggests,
presence of any potential dental causes of of these being degenerative disease such as is an anatomical problem arising when
pain. In practice an orthopantomogram osteoarthritis, but ankylosis (bony fusion the articular disc moves from its original
(OPG) may be undertaken, while preventing movement), developmental position, either anteriorly or posteriorly
in specialist centres computerized abnormalities and neoplasms (tumours) within the joint space. In some people

Dental Nursing December 2011 Vol 7 No 12 15

 Clinical

the disc may ‘pop’ back into place on over the years to treat TMJ problems.

S4S
closing, this is called a ‘reducing’ disc Normally made out of acrylic, splints can be
displacement and is one of the reasons a hard or soft and can fit over the maxillary
patient may complain of ‘clicking’ joints. or mandibular teeth. While there was no
Studies have demonstrated that while evidence of a significant difference in the
30% of healthy individuals have disc effectiveness of splint therapy compared
displacement it is significantly more with other active treatments, the use of
common in patients who complain of splints in the treatment of myofacial pain
TMJ problems. The cause of pain in dysfunction syndrome may be beneficial
patients with disk displacement is not fully (Al-Ani et al, 2004).
understood, and while disc displacement Figure 2. Occlusal splint
may play a significant role in the process, Psychological counselling

ISTOCK
the presence of displacement does not It has been demonstrated that patients
automatically mean the patient will feel suffering from TMJ pain may benefit
pain (Tasaki et al, 1996). from instruction in relaxation techniques
and coping skills. The literature suggests
Recurrent dislocation that these therapies prevent relapses that
Dislocation of the TMJ occurs when may occur with conventional therapy
the condyle moves out of the glenoid alone (Orlando et al, 2007). However,
fossa and becomes locked anterior and unfortunately these techniques are time-
superior to the articular eminence and consuming to teach and are not widely
the patient cannot close their mouth. available under the NHS.
When this occurs the surrounding
muscular may begin to spasm causing Pharmacology
discomfort. Recurrent dislocation can The two types of medication often
be very distressing for the patient, as prescribed for the treatment of TMJ
it usually happens without warning. Figure 3. Acupuncture treatment to face problems are non-steroidal anti-
Available treatments include the injection inflammatories (NSAIDs) and tricyclic
of a fibrosing agent into the joint space to non-invasive therapies. For the majority antidepressants. While there are few
reduce joint mobility or an operation to of patients this will include advice about randomized controlled trials to support
adjust the bony prominences around the resting the joints by cutting up food into their use (Mujakperuo et al, 2010),
joint (Wong and Cheng, 2004). more manageable pieces, avoidance of these medicines are often widely used
chewy foods and limitation of extreme in specialist oral surgery departments
Temporal arteritis movements such as wide yawning and to treat TMJ problems that have been
Although not strictly a problem arising chewing gum. In addition, some patients resistant to other forms of treatment.
from the TMJ, temporal arteritis is a may find benefit from heat application or
serious inflammatory condition of the massage to the side of the face. Acupuncture
temporal blood vessels that can present Acupuncture is reported to be an
with symptoms similar to TMJ pain. Jaw exercises adjunctive treatment, producing a short-
If untreated this condition can rapidly Jaw exercises are thought to help strengthen term analgesic effect in patients with
cause blindness and therefore any patients the muscles and associated structures of the painful TMJ symptoms (La Touche et
complaining of TMJ with associated TMJ. Some of the recommended exercises al, 2010) (see Figure  3). Again, accessing
visual disturbance should be referred involve guided opening and closing these treatments under the NHS is often
to a physician or maxillofacial surgery movements, manual joint distraction and difficult for patients—although, private
department as a matter of urgency. gentle tension exercises against resistance. facilities do exist.
Leaflets explaining how to perform these
Treatment for TMJ exercises are often available from a local Other treatment options
oral surgery department. Occlusal adjustment
problems—conservative and orthodontics
management Splint therapy Occlusal adjustment is the selective
The first-line treatment of TMJ problems Various types of occlusal splints (see removal of enamel from the occlusal
should always be conservative and use Figure  2) or nightguards have been used contacts of teeth to increase the number of

16  Dental Nursing December 2011 Vol 7 No 12

 Clinical

arising from myofacial pain dysfunction TMJ internal derangement and osteoarthritis
KEY POINTS syndrome. This involves the injection with magnetic resonance imaging. J Am Dent Ass
132(6): 753–61
of Botox® into masseter or temporalis
Temporomandibular joint
„„ muscles and has been shown to increase Dahlstrom L, Carlsson G (2010) Temporomandibular
(TMJ) problems affect large disorders and oral health-related quality of life. A
mouth opening and reduce pain (Freund systematic review. Acta Odontol Scand 68(2):
proportions of the population
et al, 1999). 80–5
at one time or other. Dimitroulis G (1998) Temporomandibular
disorders: a clinical update. Br Med J 317(7152):
Women are more likely to
„„ Arthroscopy and arthrocentesis 190–4
suffer from TMJ problems than These treatments are medical procedures Freund B, Schwartz M, Symington J (1999) The
men. usually undertaken under sedation use of botulinum toxin for the treatment of
or general anaesthesia in a hospital temporomandibular disorders: preliminary
TMJ problems often have
„„ findings. J Oral Maxillofac Surg 57(8): 916–21
environment. They are similar procedures
significant psychological, as Gonzalez Y, Schiffman E, Gordon S et al
well as physical causes. that allow the removal of intracapsular (2011) Development of a brief and effective
adhesions and delivery of the corticosteroid temporomandibular disorder pain screening
Conservative management
„„ betamethasone into the joint space. Both questionnaire. J Am Dent Ass 142(10): 1183–91
should always precede Gray R, Davies S, Quayle A (1994) A clinical approach
treatments have the ability to reduce pain to mandibular disorders. 1. Classification and
surgical intervention. and improve mouth opening. However, functional anatomy. Br Dent J 177(8): 429–35
No strong evidence exists
„„ when compared with arthroscopy, open Koh H, Robinson P (2003) Occlusal adjustment for
surgery has shown to be more effective treating and preventing temporomandibular joint
to suggest the single best disorders. J Oral Rehab 31(4): 287–92
treatment for TMJ disorders. (Rigon et al, 2011).
La Touche R, Goddard G, De-La-Hoz J et al
Treatment planning should (2010) Acupuncture in the treatment of pain
involve balancing the patient’s Open surgery in temporomandibular disorders: a systematic
wishes with potential risks Open surgery involves making larger cuts review and meta-analysis of randomized
controlled trials. Clin J Pain 26(6): 541–50
and benefits of treatment. in the skin to expose the TMJ. Procedures
Luther F, Layton S, Mcdonald F (2010) Orthodontics
include condylectomies (recontouring for treating temporomandibular joint (TMJ)
teeth in the intercuspal position. However, the top of the condyle to reposition disorders. Cochrane Database Syst Rev 7:
a literature review concluded that occlusal the articular disc), articular eminence CD006541
Mejersjö C, Hollender L (1984) Radiography of
adjustment cannot be recommended for recontouring (for individuals with the temporomandibular joint in female patients
the management or prevention of TMJ recurrent jaw dislocation) and partial or with TMJ pain or dysfunction. Acta Radiol Diagn
problems (Koh and Robinson, 2003). total joint replacement; however, these 25(3): 169–76
Similarly, a separate review found that procedures are usually considered the Mujakperuo H, Watson M, Morrison R, Macfarlane
T (2010) Pharmacological interventions for pain
there is no evidence to show that active ‘last resort’. in patients with temporomandibular disorders.
orthodontic treatment can prevent or Cochrane Database Syst Rev 10: CD004715
relieve temporomandibular disorders Conclusion Okeson J (1996) Guidelines for Assessment, Diagnosis,
(Luther et al, 2010). The general dental team has a role and Management of Orofacial Pain. Quintessence
Publishing Co, Inc, Chicago
to play in the diagnosis, conservative Orlando B, Manfredini D, Salvetti G, Bosco M (2007)
Hyaluronate management and referral of patients Evaluation of the effectiveness of biobehavioral
Hyaluronate is a gel-like glycosaminoglycan with TMJ pain. By understanding the therapy in the treatment of temporomandibular
disorders: a literature review. Behav Med 33(3):
that takes in water to ensure the resilience various causes and presentations of TMJ
101–18
of cartilage. Hyaluronate injections are problems it is possible to distinguish Rigon M, Pereira L, Bortoluzzi M, Loguercio A,
sometimes used for osteoarthritis of the between dental pain, TMJ disorder and Ramos A, Cardoso J (2011) Arthroscopy for
knees or hips, as it acts to cushion the the more complicated facial pains to temporomandibular disorders. Cochrane Database
Syst Rev 5: CD006385
joint and reduces pain. However, reviews ensure speedy diagnosis and management
Shi Z, Guo C, Awad M (2003) Hyaluronate for
of the evidence for its application in TMJ for our patients. DN
temporomandibular joint disorders. Cochrane
problems found that there is currently Database Syst Rev 1: CD002970
insufficient evidence to decide whether Al-Ani M, Davies S, Gray R, Sloan P, Glenny Tasaki M, Westesson P, Isberg A, Ren Y, Tallents R
A (2004) Stabilisation splint therapy for (1996) Classification and prevalence of
it was beneficial for these patients (Shi et temporomandibular pain dysfunction syndrome. temporomandibular joint disk displacement
al, 2003). Cochrane Database Syst Rev 1: CD002778 in patients and symptom-free volunteers. Am J
Berkovitz B, Moxham B, Sloan A (2011) Master Orthod Dentofacial Orthop 109(3): 249–62
Botulinum toxin Dentistry. Vol  3. Oral biology. Churchill Wong K, Cheng J (2004) Recurrent dislocation of
Livingstone Elsevier, Edinburgh temporomandibular joint treated by the dautrey
In recent years, botulinum toxin or Bertram S, Rudisch A, Innerhofer K, Pumpel E, procedure – a case report and literature review.
Botox® has been used to treat TMJ pain Grubwieser G, Emshoff R (2001) Diagnosing Hong Kong Dent J 1(1): 31–4

Dental Nursing December 2011 Vol 7 No 12 17

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