Temporomandibular Joint Dysfunction - home health advice

Overview
Definition

The temporomandibular joint (TMJ) is a synovial joint that involves the masseter, medial pterygoid, and temporalis muscles of the lower jaw movement. TMJ dysfunction, often simply but inaccurately referred to as TMJ, characteristically involves face pain, clicking sounds in the TMJ, and limited movement in the mandibular area. Terminology given to the condition has been confusing and treatment of it diverse. Physicians do not appear to agree on whether TMJ dysfunction should be treated by the medical provider, the dental professional, or both. TMJ dysfunction has a prevalence rate of about 33% in the general population. However, up to 75% percent of the population may have some symptoms with only 5% to 25% seeking treatment. TMJ dysfunction affects people of all ages and women only slightly more than men.
Etiology

Definitive etiology is unknown but probably multifactorial. Contributing causes include the following.

* Malocclusion controversial as a causal factor
* Bruxism (jaw clenching) leading to masticatory muscle fatigue and spasm
* Disk derangement
* Trauma to the area
* Synovitis
* Psychophysiologic factors

Risk Factors

* Women seek treatment twice as often as men
* Age 30 to 50
* Nutritional or metabolic disorders
* Chronic bruxism
* Occlusal problems
* Psychosocial stress especially bereavement, illness, divorce, moving; depression is a risk for chronicity
* Unfavorable incisor relationship overbite, overjet, negative overbite

Signs and Symptoms

* Orofacial pain usually a chronic, unilateral, dull pain that may extend to the eyes and ears; worsens during mastication; masticatory muscle tenderness
* Decreased mandibular range of motion especially in the morning; jaw may lock
* Clicking and/or crepitus noises (however, up to 50% of the population may have such noises without pain or other TMJ dysfunction symptoms)
* Headache often chronic
* Earache, tinnitus, blocked sensations
* Neck pain
* Dizziness, vertigo
* Aggravated by occlusal problems
* Flattened molar prominences from chronic bruxism
* Chewing exacerbates all symptoms

Differential Diagnosis

* Numerous other causes of head, neck, or ear pain (e.g., sinusitis, acute otitis media, acute otalgia, parotitis)
* Neuralgias trigeminal, herpes zoster, geniculate
* Rheumatoid arthritis and osteoarthritis
* Condylar hyperplasia
* Gout, with accompanying tophi
* Odontogenic pain
* Ankylosing spondylitis
* Neoplasia
* Congenital disorders

Diagnosis
Physical Examination

The muscles in the area of the TMJ may be palpated for tenderness and fasciculations or spasms; palpate as the patient opens and closes jaw. Face is checked for asymmetry or inflammation. Joint clicking or scraping sounds may be audible. The patient's mandibular range of motion may be limited. The teeth may show evidence of bruxism or jaw clenching, such as wear facets. A neurological examination should be given if any signs of neurological dysfunction are evident (e.g., numbness).
Pathology/Pathophysiology

* Limited mandibular range of motion: <50 mm opening, <10 mm protusively and laterally
* Intracapsular diseases infection, tissue, or degenerative joint disease
* Spasms of the masseter and internal pterygoid muscles
* Nonserous inflammation from mechanical microlesions of interfibrillar connective tissue
* Inflammation of articular and periarticular tissue
* Release of neuropeptides
* Osteoarthritic joint irregular surfaces, morphologic changes
* Anterior displacement of articular disk within joint, preventing forward translation of mandibular condyle

Imaging

Unless there is suspicion of degenerative disease or disk derangement, imaging should not be performed routinely. Imaging can reveal osseous tumors, articular disk problems, condylar erosion, osteophytes, heterotopic bone, or metastatic disease. Panoramic dental radiographs reveal occlusion or other dental problems. Magnetic resonance imaging is the medium of choice for bony and soft tissue visualization and determination of joint effusion, avascular necrosis, or intracapsular TMJ disease. Arthrography is an invasive technique but allows visualization of the condyle in relationship to the disk through tomography recorded on video camera.
Other Diagnostic Procedures

* Often diagnosed by a dentist
* History and physical examination of the masticatory system

Treatment Options
Treatment Strategy

Many primary physicians see TMJ dysfunction largely as a psychophysiologic condition, while others evaluate it as a dental problem. TMJ dysfunction is treated successfully in 75% of patients who employ multifaceted treatment plans.
Drug Therapies

* Analgesics aspirin or nonsteroidal anti-inflammatory drugs no significant long-term benefits; patient-reported short-term benefit; gastrointestinal side effects
* Minor tranquilizer/muscle relaxants bedtime use reduces spasms and pain; diazepam 2 mg every hour or as needed for three to five days
* Intramuscular injections local anesthetic, longer periods of relief with repeated injections; 2% lidocaine hydrochloride
* Antidepressants for refractory pain; e.g., nortriptyline 25 mg every hour or as needed
* Intra-articular cortisone injections intractable cases only, controversial; side effects include infection, local structure damage, usual systemic effects

Surgical Procedures

* High intracapsular condylectomy, disk correction or replacement; when all other measures have failed
* Arthroscopy less invasive and provides good symptom relief; low incidence of complications; long-term benefit unclear

Complementary and Alternative Therapies

The goal is to decrease inflammation and provide pain relief. Physical approaches can be quite effective. Although research is scanty, a clinical trial of CAM therapies seems reasonable, given the irreversibility of surgery. Biofeedback may be efficacious in treating TMJ and in preventing recurrence.
Nutrition

* Essential fatty acids regulate arachidonic acid metabolites to decrease inflammation; 1,000 to 3,000 mg/day of mixed omega-3 and omega-6.
* Soft foods high in flavonoids provide antioxidants to decrease pain caused by free radical buildup in the joint.
* Avoid saturated fats, fried foods, and caffeine, all of which increase inflammation. Avoid chewing gum.

Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes).

* St. John's wort (Hypericum perforatum) may improve serotonin levels affected in TMJ. Oil may be applied topically. Oral dose is 250 mg tid.
* Cramp bark (Viburnum opulus) and lobelia (Lobelia inflata) are antispasmodic. Rub 5 drops tincture of each herb into joint. Do not apply to broken skin.

Homeopathy

An experienced homeopath would consider an individual's constitutional type to prescribe a more specific remedy and potency. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

* Causticum for burning pains that are better in rainy weather and worse in dry weather
* Hypericum perforatum for sharp shooting pains, especially after an injury or dental work
* Ignatia for tension in the jaw after a grief or conflict
* Kalmia for face pain especially with other joint pains/arthritis
* Magnesia phosphorica for muscle cramps that feel better with heat and pressure
* Rhus toxicodendron for pains that feel better in the morning and in dry weather, and worse after movement or in wet weather
* Ruta graveolens for pains from overuse or injury that are better with rest

Physical Medicine

Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste to decrease inflammation, provide pain relief, and enhance healing. Use hot packs and ice wrapped in a wash cloth and apply to area. Alternate three minutes hot with one minute cold and repeat three times. This is one set. Do two to five sets/day.
Acupuncture

May help decrease spasm and reduce frequency and intensity of symptoms
Massage

Cranio-sacral and chiropractic manipulation may be useful to decrease muscle spasm, provide pain relief, and prevent recurrence.
Patient Monitoring

Ongoing assessment of conservative therapies is appropriate.
Other Considerations
Prevention

* Stress reduction
* Awareness and efforts to stop bruxism and clenching

Complications/Sequelae

* Prolonged teeth clenching or grinding, trauma, infection, or connective tissue disease may cause severe malocclusion or intracapsular joint derangement, which may result in degenerative joint disease or arthritis. The diagnosis is confirmed by radiologic examination. Although rare, the implications are serious and may require teeth regrinding or surgery. Patients with severe grinding may benefit from nighttime use of a splint or bite guard.
* Severe trismus apply refrigerant spray (e.g., ethyl chloride), then standard therapies
* Arthritic conditions

Prognosis

TMJ dysfunction is almost always self-limiting. Irreversible treatments, such as teeth regrinding and surgery, are rarely called for and have a limited efficacy.
Pregnancy

N/A
References

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