TMJ Disorder

Question 1

What is the definition of TMD?

Answer 1

Group of musculoskeletal conditions that involve the TMJs, masticatory muscles and all associated tissues

Question 2

What are some suggested aetiology of TMD?

Answer 2

Genetics
Females
Nervous system - peripheral and central sensitisation, endogenous pain modulation
Psychological - catastrophizing, stress, depression
Co-morbidities - fibromyalgia, headaches, lower back pain, irritable bowel syndrome

Question 3

What pain history questions do we need to ask those with TMDs?

Answer 3

SOCRATES
Pain History
* Site = TMJs, muscles of mastication, within ear
* Onset = sudden or gradual (over days)
* Character = aching, deep, continuous +/- acute flares
* Radiation = ear, angle of jaw, temple, teeth
* Assoc. & alleviating = rest, analgesia
* Timing = continuous +/- acute flares
* Exacerbating factors = chewing, yawning, prolonged mouth opening
* Severity = variable (sometimes 1, sometimes 10)

Question 4

What are the 3 clinical presentations of TMD?

Answer 4

1. Myalgia = muscle pain (in jaw, temple, ear) & arthralgia = joint pain
2. Intra-articular disorders = click, pop, or snap on opening&closing, limited opening, history of locking, crepitus (cracking noise in joint)
3. Acute or chronic (over 3 months)

Question 5

What are the main differential diagnosis for TMD? use these categories:
dental, paranasal sinus, salivary, vascular, neuropathic. headache, malignancy, referred pain

Answer 5

1. Dental = through assessment for caries and cracked teeth
2. Paranasal sinuses = sinusitis (pain on bending forwards)
3. Salivary = parotid obstruction (mumps – fever, malaise OR unilateral)
4. Vascular = giant cell arteritis
5. Neuropathic = trigeminal neuralgia (electric shock pan unilaterally and can overlie TMJ region or radiate here), trigeminal autonomic cephalgia’s
6. Headache = tension headache, migraine
7. Malignancy = H&N, ENT, TMJ

Question 6

What are the red flags associated with TMD?

Answer 6

1. Giant cell arteritis (temporal arteritis) = inflammation within arteries
2. Trigeminal neuralgia = paroxysmal, unilateral lancinating pain
3. Malignancy = history of malignancy, facial asymmetry, trismus (difficulty opening), occlusal changes, sensory or motor changes (loss of hearing), recurrent epistaxis, lymph nodes, unusual pain

Question 7

What are common extra and intra oral findings with TMD?

Answer 7

Extra-oral examination for TMJ:
* Palpate TMJs for tenderness and crepitus
* Palpate muscles of mastication for tenderness and hypertrophy
* Limitation of opening – use fingers to assess this – usually two fingers or less suggests limitation
* Lymph nodes
* Asymmetry – facial, lymph nodes, parotid glands
* Tenderness overlying temporal artery – urgent referral

Intra-oral examination:
* Evidence of parafunctional habits
* Linea alba and tongue scalloping
* Non carious tooth surface loss (grinding)
* Occlusal derangement

Question 8

What is the management of TMD?

Answer 8

1. Reversible = conservative treatments, advice (do not chew gum, warm and cold compresses, analgesics), exercise, physiotherapy, relaxation, mindfulness, sleep hygiene, CBT
2. Irreversible = orthodontics, prosthodontic reconstruction, surgery
3. Medications = paracetamol, NSAIDs, tricyclic antidepressants, corticosteroids botox