Am Fam Physician. 2023;107(1):52-58
Patient information: See related handout on temporomandibular disorders.
Author disclosure: No relevant financial relationships.
Temporomandibular disorders affect between 5% and 12% of the population and present with symptoms such as headache, bruxism, pain at the temporomandibular joint, jaw popping or clicking, neck pain, tinnitus, dizziness, decreased hearing, and hyperacuity to sound. Common signs on physical examination include tenderness of the pterygoid muscles, temporomandibular joints, and temporalis muscles, and malocclusion of the jaw and crepitus. The diagnosis is based on history and physical examination; however, use of computed tomography or magnetic resonance imaging is recommended if the diagnosis is in doubt. Nonpharmacologic therapy includes patient education (e.g., good sleep hygiene, soft food diet) and physical therapy. Pharmacologic therapy includes nonsteroidal anti-inflammatory drugs, cyclobenzaprine, tricyclic antidepressants, and gabapentin. Injections of the temporomandibular joints with sodium hyaluronate, platelet-rich plasma, and dextrose prolotherapy may be considered, but the evidence of benefit is weak. A referral to oral and maxillofacial surgery is indicated for refractory cases.
Temporomandibular disorders (TMDs) include conditions that cause pain or dysfunction with the muscles of mastication or the temporomandibular joint (TMJ). This rapid evidence review focuses on patient-oriented evidence for managing patients with issues related to the temporomandibular region.
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| There is insufficient evidence to support the use of psychological therapy for the treatment of pain or psychological distress associated with temporomandibular disorders.15 | B | Systematic review with meta-analysis of lower quality clinical trials with inconsistent findings |
| Occlusal splints decrease pain and improve mandibular movement.22 | B | Systematic review of lower-quality clinical trials with inconsistent findings |
| Naproxen should be recommended for initial pharmacotherapy of temporomandibular disorders.23,24 The addition of cyclobenzaprine is recommended if there is clinical evidence of muscle spasm.25 | A | Randomized controlled trials of good quality |
| Corticosteroid injections into the temporomandibular joint are no better than arthrocentesis with saline and should be avoided due to potential cartilage damage.30 | B | Systematic review of lower-quality clinical trials with inconsistent findings |
| Recommendation | Sponsoring organization |
|---|---|
| Avoid routinely using irreversible surgical procedures such as braces, occlusal equilibration, and restorations as the first treatment of choice in the management of temporomandibular joint disorders. | American Dental Association |
Epidemiology and Risk Factors
The prevalence of TMDs is between 5% and 12%.1
Managing TMDs is estimated to cost $4 billion annually in the United States.1
TMDs often present with comorbid psychopathology (e.g., posttraumatic stress disorder, depression, anxiety) and other comorbid conditions such as chronic pain and fibromyalgia.2
TMDs have a bimodal peak at 21 and 53 years of age with a female-to-male ratio of 3-to-1.3
TMDs occur due to complex interactions involving biomechanical, psychosocial, and genetic factors.4
Causes of TMDs include overuse (e.g., bruxism, nocturnal clenching, spasms), trauma, infection (e.g., herpes zoster, abscess), dental disorders (e.g., caries), and autoimmune diseases.5
TMDs are classified as chronic if they persist for more than three months.6
Diagnosis
SIGNS AND SYMPTOMS
The differential diagnosis for TMDs is summarized in Table 1.7
The differential is extensive but can be classified as intra-articular or extra-articular (Table 2).1,5,6,8
Common symptoms include headache (79%), bruxism (58%), pain at the TMJ (54%), otalgia (52%), jaw popping or clicking (51%), neck pain (51%), tinnitus (37%), dizziness (37%), decreased hearing (36%), and hyperacuity to sound (23%).6,9,10
Common signs on palpation include tenderness of the pterygoid muscles, TMJs, temporalis muscles, angle of the mandible, posterior cervical area, and sternocleidomastoid muscle9 (Figure 16).
Other signs include malocclusion with lateral deviations of the jaw on opening and closing, slow or staggered movements of the jaw, inability to open the jaw more than 30 to 35 mm, and worn incisal surfaces of the teeth.9 Clicking, popping, snapping, or locking sensations are common with jaw movement.8 Crepitus is a common finding in patients with degenerative joint disease of the TMJ.5
Consider other diagnoses if there is no pain with jaw movement or the cranial nerve examination is abnormal.5
Validated diagnostic instruments have been published in the past 10 years, such as the Diagnostic Criteria for TMDs, which is divided into Axis 1 (focusing on the TMJ and associated structures) and Axis 2 (assessing for psychosocial comorbidity).5,8
A simple screening method is the TMD Pain Screener tool.11 Although the authors report excellent sensitivity and specificity in a validation study, the design of that study with confirmed cases compared with the healthy pain-free control group inflates the apparent accuracy 8,11 (Table 311).
Patients with jaw trauma or a suspected dental abscess should be sent for dental panoramic tomography and referred to oral and maxillofacial surgery.6
Subscribe
From $145- Immediate, unlimited access to all AFP content
- More than 130 CME credits/year
- AAFP app access
- Print delivery available
Issue Access
$59.95- Immediate, unlimited access to this issue's content
- CME credits
- AAFP app access
- Print delivery available
Article Only
$25.95- Immediate, unlimited access to just this article
- CME credits
- AAFP app access
- Print delivery available
