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Review of Diagnosis and Treatment of TMJ Disorders
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Am Fam Physician. 1998 Nov 15;58(8):1841-1842.
Approximately 70 percent of adults have at least one sign of a temporomandibular joint (TMJ) disorder, but only 25 percent report symptoms and only about 5 percent seek medical intervention. Dimitroulis reviews the clinical features of TMJ and the role of conservative treatment measures.
The most common type of TMJ disorder is myofascial pain and dysfunction, usually the result of bruxism or jaw clenching. These habits may be related to stress, anxiety, depression or chronic pain. Less commonly, TMJ is due to mechanical problems or osteoarthrosis.
The three cardinal features of TMJ are orofacial pain, restricted jaw function and noise in the joint. Patients may also report pain in the ear, neck and shoulder, tinnitus and generalized headaches, as well as stress-related symptoms, especially insomnia. Jaw movement is usually described as “a tightness.”Patientswho describe the jaw suddenly “sticking” or “catching” usually have mechanical dysfunction of the joint. A classic presentation is pain in front of the tragus, with radiation to the ear, lower jaw, cheek and temple. Pain is usually worse in the morning and may occur in cyclical episodes. Patients may also report clicking or grating sounds during chewing and progressive limitation of mouth opening.
Tenderness around the joint may be found on physical examination. The joint should be examined during opening, closing and lateral excursion of the mandible. Joint clicking may be detected by palpation or by placing a stethoscope in front of the tragus. Radiographs or even magnetic resonance imaging may be useful if joint derangement is suspected. A careful physical examination is required to exclude causes of pain in the ear, teeth, mouth, neck, jaw and salivary glands. Pain from disorders of these structures may mimic TMJ.
Conservative therapy is effective in over 80 percent of cases. It is essential to thoroughly explain the condition and educate the patient about it. Patients should be advised to identify and address sources of stress and to modify chewing and other habits that cause excessive jaw movement. Massage, application of local moist heat and exercises are all important recommendations. Nonsteroidal anti-inflammatory drugs are useful if pain is due to synovitis or myositis. Low dosages of tricyclic antidepressants or tranquilizers have been used to reduce stress if this is a significant contributor to TMJ syndrome. All drugs should be prescribed in a specified regimen for a defined period of time. The use of “as-needed” medications is unlikely to be successful and may lead to dependency or overuse. Occlusal dental devices are commonly prescribed for TMJ and are reported to alleviate symptoms in over 70 percent of patients. In selected patients, physical therapy, behavioral therapy or psychotherapy may be indicated. Surgical intervention is usually required in fewer than 5 percent of patients with TMJ disorders.
Dimitroulis G. Temporomandibular disorders: a clinical update. BMJ. July 18, 1998;317:190–4.
Copyright © 1998 by the American Academy of Family Physicians.
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