A Simpler Way to Diagnose Temporomandibular Joint Disorder

Temporomandibular disorder (TMD) has a prevalence of between 5% and 12% in the United States, with an estimated cost of $4 billion annually. TMD has bimodal peaks in prevalence in early adulthood (21 years) and mid-adulthood (53 years). Females are more often impacted compared to males at a ratio of 3:1. TMD is often comorbid with psychological conditions such as trauma or anxiety. The etiology of TMD is broad and includes overuse, dental conditions (eg, caries), infection, or autoimmune disease. Over 30% of patients in one study saw at least 2 to 3 professionals before receiving a diagnosis, highlighting the need for more timely diagnosis. 

The diagnosis of TMD is primarily clinical, with most patients noting headaches, temporomandibular joint pain, jaw popping/clicking, and otalgia. Less common symptoms include dizziness and decreased or increased acuity to sound. Several clinical diagnostic guides exist, including the Diagnostic Criteria for Temporomandibular Disorders, but have limited utility in the general practice setting due to perceived complexity and time commitment.

Recently, the Brief Diagnostic Criteria for Temporomandibular Disorders simplified the criteria into palpation at 3 bilateral points: the temporalis and masseter muscles, as well as the lateral pole of the temporomandibular joint (just in front of the tragus of the ear). Dysfunction at these points on exam has a sensitivity of 88%, specificity of 98%, positive likelihood ratio of 33, and negative likelihood ratio of 0.15 for TMD, making it an effective tool for clinical use. There is not yet a study comparing this more simplified protocol with the more extensive one previously mentioned.

Imaging is not necessary for diagnosis but may be recommended for patients in whom the diagnosis is uncertain or for patients in whom conservative treatment fails (typically after 2-4 weeks), motor/sensory deficits are present, or there is trauma to the jaw or a suspected abscess. Computed tomography is recommended for evaluation of bony abnormalities. Magnetic resonance imaging is better suited for evaluating the intra-articular surfaces and disc.

Initial treatment is often conservative and includes patient education, non-steroidal anti-inflammatory medications, and psychosocial interventions. Additional treatment is guided by the type of TMD (intra-articular vs extra-articular), with muscle relaxants recommended for patients with extra-articular (ie, muscular strain) TMD. Nortriptyline, gabapentin, occlusal splints, and injections and imaging may be considered for patients with intra-articular TMD that do not respond to conservative treatment.

More information on the diagnosis and management of TMD may be found in this American Family Physician Rapid Evidence Review. Additional information for patients may be found in this patient handout.