DESCRIPTION 
- Myofascial pain causing temporomandibular joint (TMJ) dysfunction
- Prevalence of 40–75% of 1 sign of TMJ disorder
- Most common in 20–50-yr-olds
- Females seek treatment more frequently
- 40% have symptoms that resolve spontaneously
- TMJ is a synovial joint:
- Allows for hinge and sliding movements
- Articular disorders:
- Congenital or developmental
- Degenerative joint disorders:
- Trauma
- TMJ hypermobility:
- TMJ hypomobility:
- Infection
- Neoplasm
- Masticatory muscle disorders:
- Local myalgias
- Myositis
- Muscle spasm
- Contracture
- Myofascial pain disorder
- TMJ clicking:
- May be normal finding; present as a transient finding in 40–60% of the population
- TMJ motion:
- Typical range is 35–55 mm (maxillary to mandible incisors)
- Limited by adhesions within the joint or disk displacement or trismus from muscle spasm
- Intra-articular disk disorder:
- Anterior displacement with reduction:
- Displacement in closed mouth position
- Often with a click and variable pain with opening mouth
- May worsen over time
- Anterior disk displacement without reduction:
- Disk is a mechanical obstruction to opening mouth
- Maximal opening may be 20–25 mm
- Often difficult to correct
ETIOLOGY
TMJ dysfunction is poorly understood:
- Multifactorial:
- Bruxism (teeth grinding)
- Trauma
- Malocclusion
- Onset may be related to stress
[Outline]
SIGNS AND SYMPTOMS
History
- Preauricular pain:
- Constant but with fluctuating intensity
- Dull and aching
- May be referred to the ipsilateral ear, head, neck, or periorbital region
- Exacerbated by mandibular movement (pathognomonic)
- More conspicuous at night and may cause insomnia
- Often worsens through the day
- Tongue, lip, or cheek biting
- Ear pain
- Ear fullness
- Tinnitus
- Dizziness
- Neck pain
- Headache
- Eye pain
Physical Exam
- Joint sounds:
- Popping or clicking sensation with TMJ articulation
- A palpable or audible click with opening and closing
- Not sufficient for diagnosis if not accompanied by pain or other dysfunction
- Misalignment and limited range of motion:
- Dentoskeletal malocclusion or lateral deviation
- Open or closed locking of the jaw
- Tenderness over the muscles of mastication and TMJ:
- Masseter muscle most commonly painful
- Pain with dynamic loading (bite on gauze)
ESSENTIAL WORKUP
- Diagnosis based on history and physical exam
- Exclude other causes of headache and facial pain
DIAGNOSIS TESTS & INTERPRETATION
Lab
No specific lab tests are indicated unless there is concern for other disease process, i.e., ESR may help distinguish temporal arteritis from TMJ dysfunction.
Imaging
- Panorex is the screening radiograph of choice:
- CT: Best for evaluating bony structures for fractures, dislocations, etc.
- MRI: Best imaging for nonreducing displaced disks:
- Allows for better visualization of joints simultaneously
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
Provide comfort and reassurance
INITIAL STABILIZATION/THERAPY
Make sure airway is patent
ED TREATMENT/PROCEDURES
- Acute therapeutic options:
- Patient reassurance and education—"usually mild and self-limited"
- Rest
- Heat
- Analgesics and anxiolytics
- Urgent reduction of open or closed locking TMJ
- Reduction of TMJ dislocation:
- Dislocation usually bilateral
- IV muscle relaxant may be helpful
- Often requires procedural sedation
- Monitor airway
- May face the patient or perform from behind the patient
- Protect thumbs with gauze and/or tongue depressors
- Thumbs rest on intraoral surface of mandible
- Fingers wrap around jaw
- Firm, progressive downward pressure as jaw is guided 1st in a caudal direction and then posteriorly
- Physical therapy—moist heat or ice packs
- Pain site injections with mixture of steroids/lidocaine
- Outpatient management:
- Combination pharmacotherapy:
- NSAIDs
- Muscle relaxants
- Antidepressants
- Sedative hypnotics
- Home physical therapy—moist heat or ice packs and mechanically soft diet
- Caution not to open mouth > 2 cm for 2 wk
- Avoid triggers such as gum chewing
- Occlusal appliance worn during sleep
- Referral to dentist or oral–maxillofacial surgeon
MEDICATION
First Line
- Naproxen: 250–500 mg PO BID (peds: 10 mg/kg/d PO div. q12h)
- Cyclobenzaprine: 5–10 mg PO TID (peds: 5–10 mg PO TID if > 15 yr old); caution with hepatic impairment
- Diazepam: 2–10 mg PO BID–TID (peds: < 12 yr old 0.12–0.8 mg/kg/d PO div. q6–8h); poor efficacy when used alone
- Ibuprofen: 600 mg (peds: 10 mg/kg) PO q8h; less effective than naproxen
Second Line
- Nortriptyline: 10–50 mg PO qhs
- Narcotic analgesic
- Sedative hypnotics
[Outline]
DISPOSITION
Admission Criteria
TMJ syndrome can be managed on an outpatient basis unless a locked or dislocated joint cannot be reduced
Discharge Criteria
Treat as outpatient with pain medication, muscle relaxants, and warm compresses
FOLLOW-UP RECOMMENDATIONS
Patients with TMJ syndrome may need referral to ENT, oral surgeon, or dentist for further care
[Outline]