Temporomandibular Disorders

The vast majority of temporomandibular disorders, whether articular or muscular, can be treated with noninvasive, nonsurgical and reversible interventions.

The temporomandibular joint (TMJ) may be affected by diseases that are:

• Congenital
• Developmental
• Infectious
• Inflammatory
• Neoplastic, as seen in other joints
• Traumatic

However, the most common affliction of the TMJ and masticatory apparatus is a group of functional disorders with associated pain that occurs predominantly in women and was previously known as the TMJ pain dysfunction syndrome.

Temporomandibular disorders are defined as a subgroup of craniofacial pain problems that involve the TMJ, masticatory muscles and associated head and neck musculoskeletal structures. Patients with temporomandibular disorders most frequently present with pain, limited or asymmetric mandibular motion and TMJ sounds. The pain or discomfort is often localized to the jaw, TMJ and muscles of mastication. Common associated symptoms include:

• Dizziness
• Ear pain and stuffiness
• Headaches
• Neck pain
• Tinnitus

In some cases, the onset is acute and symptoms are mild and self-limiting. In other patients, a chronic temporomandibular disorder develops with persistent pain and physical, behavioral, psychological, and psychosocial symptoms similar to those of patients with chronic pain syndromes in other areas of the body (e.g., arthritis, low back pain, chronic headache, fibromyalgia, and chronic regional pain syndrome), all requiring a coordinated interdisciplinary diagnostic and treatment approach.

The prevalence among adults in the United States of at least one sign of temporomandibular disorders is reported as 40 to 75% and among those with at least one symptom, 33%. TMJ sounds and deviation on opening the jaw occur in approximately 50% of otherwise asymptomatic persons; these are considered within the range of normal and do not require treatment. Other signs, such as decreased mouth opening and occlusal changes, occur in fewer than 5% of the general population. 12 temporomandibular disorders are most commonly reported in young to middle-aged adults (20 to 50 years of age). The female-to-male ratio of patients seeking care has been reported as ranging from 3:1 to as high as 9:1. Despite the high prevalence of temporomandibular disorders, signs, and symptoms, only 5 to 10% of those with symptoms require treatment, given the wide spectrum of symptoms and the fact that the natural history of this disorder suggests that in up to 40% of patients, the symptoms resolve spontaneously.

Currently, management of temporomandibular disorders consists of a combination of:

• Behavioral medicine
• Counseling
• Home self care
• Jaw-appliance therapy
• Pharmacotherapy
• Physical medicine
• Physiotherapy
• Surgery

Surgery is performed only to treat structural anatomic pathology that is producing pain and dysfunction. Surgical procedures include arthrocentesis, arthroscopy, open arthrotomy, and combined joint and reconstructive jaw procedures.

The vast majority of temporomandibular disorders (approximately 85 to 90%), whether articular or muscular, can be treated with noninvasive, nonsurgical and reversible interventions. For patients with intra-articular disorders that do not respond to a reasonable course of nonsurgical interventions (generally three to six months in length), surgical therapy may be considered if the pain is substantial and the limitation of function severe enough to interfere with activities of daily living.

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Scrivani SJ, Keith DA, Kaban LB: Temporomandibular Disorders – Medical Progress. New England J Med, 359:2693-2705, December 18, 2008.

Mehta NR, Scrivani SJ: Temporomandibular Disorders. In Bajwa ZH. Wooton J, Warfield CA (eds.): Principles and Practice of Pain Medicine. 2nd Ed., McGraw-Hill Publishing Co., 2013.