Clinical

Diagnosis, treatment and

management of TMJ disorders
Temporomandibular joint disorders, commonly called TMJ, are a group of conditions that cause pain
and dysfunction in the jaw joint and the muscles that control jaw movement. It is important that dental
nurses can identify these patients and provide them with information and support about their condition

T
emporomandibular joint
disorders is a collective
term embracing a number
of clinical problems that
involve the muscles of mastication and
the temporomandibular joint (TMJ),
and its associated structures (Okeson,
1996). Pain is the defining feature of
TMJ disorders and is the most common
reason why patients seek care; other
complaints may involve joint noises or
limited or asymmetrical jaw movement
(Dimitroulis, 1998).
The aetiology of a large number of
TMJ disorders is still not clear, although
the literature suggests parafunctional
activity, or habitual movements such
as bruxism or tooth clenching. Other
factors include hormonal influences,
stress, previous trauma to the joint,
the shape of the TMJ and degenerative Figure I. A dissection of the temporomandibular joint
change within the joint (Rigon et al,
2011). It is thought that the prevalence al, 2003) and in women (Luther et al, the external auditory meatus or the bony
of TMJ problems may be up to 76% of 2010). Research shows that quality of auditory canal. Lateral to the joint lies the
the population, being more prevalent life can be significantly impaired among zygomatic arch and medial lies the styloid
in patients aged 20-40 years (Shi et patients suffering from TMJ dysfunction process.
(Dahlstrom and Carlsson, 2010). This The TMJ is a synovial joint capable
highlights the importance of recognizing, of gliding, hinging, sliding and slight
Graham Cope is honorary senior diagnosing and treating patients with rotation. A feature of this joint is the
research fellow, Department of these problems as effectively as possible. meniscus, or articular disc', which lies
Medicine and Dentistry, University between the condylar head and glenoid
of Birmingham; and Anwen Cope Anatomy of the TMJ fossa. This acts as a shock absorber for
is postgraduate researcher. School The temporomandibular joint {Figure 1) the joint and allows smooth movement
of Medicine, Cardiff University, is formed by the articulation between the of the lower jaw. The disc is composed of
Wales condyle of the mandible and the glenoid fibrocartilagenous tissue and is separated
fossa, a concavity in the temporal bone of into three function areas: the anterior
Email: grahamcope@btconnect.com the skull. At the front of the glenoid fossa band; the intermediate zone and the
lies the articular eminence and at the back posterior band. The disc is attached

682 Dental Nursing December 2011 Vol 7 No 12

 clinical

anteriorly to the superior head of the

lateral pterygoid muscle and merges Box 1. Muscles involved in jaw movements
periplierally with the joint capsule and
then posteriorly it is attached to the Actions Muscles
capsule by a bilaminar zone (Berkovitz Depression (open mouth) Lateral pterygoid, suprahyoid and infrahyoid
et al, 2011). The capsule is a fibrous
Elevation (close mouth) Temporalis, masseter, medial pterygoid
membrane that surrounds the joint and
attaches to the articular eminence, the Protrusion (Sticking chin forwards) Masseter, lateral pterygoid, medial pterygoid
articular disc and the neck of the condyle. Retrusion (Moving chin backwards) Temporalis and masseter
The f.brous capsule is thickened laterally
to form the lateral (temporomandibular) Lateral Movements (side-to-side grinding) Temporalis, pterygoid muscles and masseter
ligament, which reinforces the lateral
part of the capsule. The joint is also
Box 2. Symptoms associated with TMJ disorders
supported by the stylomandibular and
sphenomandibular ligaments. i Jaw pain (either at rest or when eating)
The movements of the TMJ are mainly
' Headache (may be worse in the morning)
controlled by the muscles of mastication:
temporalis, masseter, lateral and medial ' Limitation of jaw opening
pterygoids {Box 1). Opening the mouth ' Locking of the jaw
requii^es two distinct movements: first
• Earache
is the rotation of the condylar head
anteriorly within the fossa. The second ' 'Clicking', 'popping' or 'grinding' sounds of the TMJ
is a tianslational slide where the condyle ' Dull ache in face or neck
and I he articular disc move anteriorly
down the articular eminence of the tomography (CT) or magnetic resonance can also occur. Among individuals with
temporal bone. imaging (MRI) may also be undertaken. TMJ disorders, around 11 % have symptoms
of TMJ-osteoarthritis (Mejersjö and
Problems arising from Myofacial pain dysfunction HoUender, 1984) and a significant number
the TMJ syndrome of these will have had some previous
Diagnosis Myofacial pain dysfunction syndrome is trauma to the joint. TMJ-osteoarthritis
Some of the presenting symptoms of the most common temporomandibular is characterized by breakdown of the
TM) problems are presented in Box 2. disorder. This is one of many names articular cartilage, architectural changes in
It is important to record in a patient's for this condition including: facial the bone and degeneration of the synovial
clinical history: description and arthromyalgia, TMJ dysfunction tissues. The most common symptom of
duration of pain or other symptoms, syndrome, pain dysfunction syndrome TMJ-osteoarthritis is painful joints, while
any exacerbating or relieving factors and craniomandibular dysfunction (Gray other symptoms include limitation of jaw
and any previous interventions, either et al, 1994). Patients usually, although opening, coarse grinding noises and a
physical or pharmacological. Recently, not always, present with a dull, unilateral previous history of clicking. Characteristic
a novel questionnaire for screening for pain spreading out from the TMJ. The appearance of osteoarthritis of the TMJ
TMJ disorders was developed. This was pain is likely to be reduced by heat on OPGs include flattening and beaking
to idiintify patients who require further application and rest, but exacerbated by of the condylar head with evidence of
clinical evaluation and to aid in the eating, chewing gum or clenching the osteophyte formation, while MRIs may
diagnostic process (Gonzalez et al, 2011). teeth together. Typical triggers include show a more detailed picture of the
On examination, the dentist should stress, fatigue, depression and bruxism. destruction and sclerosis occurring within
note noises arising from the joint the joint (Bertram et al, 2001).
area, deviation of mandible on either Degenerative disease
opening or closing of the jaw, tenderness The TMJ is susceptible to all conditions Disc displacement
of musculature of mastication and the that affect other joints. The most common Disc displacement, as the name suggests,
presence of any potential dental causes of of these being degenerative disease such as is an anatomical problem arising when
pain. In practice an orthopantomogram osteoarthritis, but ankylosis (bony fusion the articular disc moves from its original
(OPG) may be undertaken, while preventing movement), developmental position, either anteriorly or posteriorly
in specialist centres computerized abnormalities and neoplasms (tumours) within the joint space. In some people

Dentcl Nursing December 2011 Vol 7 No 12 683

 clinical
the disc may 'pop' back into place on
closing, this is called a 'reducing' disc
displacement and is one of the reasons a
patient may complain of 'clicking' joints.
Studies have demonstrated that while
30% of healthy individuals have disc
displacement it is significantly more
common in patients who complain of
TMJ problems. The cause of pain in
patients with disk displacement is not fully
understood, and while disc displacement
may play a significant role in the process,
the presence of displacement does not
automatically mean the patient will feel
pain (Tasaki et al, 1996).
Recurrent dislocation
Dislocation of the TMJ occurs when
the condyle moves out of the glenoid
fossa and becomes locked anterior and
superior to the articular eminence and
the patient cannot close their mouth.
When this occurs the surrounding
muscular may begin to spasm causing
discomfort. Recurrent dislocation can
be very distressing for the patient, as
it usually happens without warning.
Available treatments include the injection
of a fibrosing agent into the joint space to
reduce joint mobility or an operation to
adjust the bony prominences around the
joint (Wong and Cheng, 2004).
Temporal arteritis
Although not strictly a problem arising
from the TMJ, temporal arteritis is a
serious inflammatory condition of the
temporal blood vessels that can present
with symptoms similar to TMJ pain.
If untreated this condition can rapidly
cause blindness and therefore any patients
complaining of TMJ with associated
visual disturbance should be referred
to a physician or maxillofacial surgery
department as a matter of urgency.
Treatment for TMJ
problems—conservative
management
The first-line treatment of TMJ problems
should always be conservative and use
684
Figure 2. NTI occlusal splint
Figure 3. Acupuncture treatment to face
non-invasive therapies. For the majority
of patients this will include advice about
resting tbe joints by cutting up food into
more manageable pieces, avoidance of
chewy foods and limitation of extreme
movements such as wide yawning and
chewing gum. In addition, some patients
may find benefit from heat application or
massage to the side of tbe face.
Jaw exercises
Jaw exercises are thought to help strengthen
the muscles and associated structures of the
TMJ. Some of the recommended exercises
involve guided opening and closing
movements, manual joint distraction and
gentle tension exercises against resistance.
Leaflets explaining bow to perform these
exercises are often available from a local
oral surgery department.
Splint therapy
Various types of occlusal splints (see
Figure 2) or nightguards have been used
over the years to treat TMJ problems.
Normally made out of acrylic, splints can be
hard or soft and can fit over the maxillary
or mandibular teeth. While there was no
evidence of a significant difference in the
effectiveness of splint therapy compared
with other active treatments, the use of
splints in the treatment of myofacial pain
dysfunction syndrome may be beneficial
(AI-Ani et al, 2004).
Psychological counselling
It has been demonstrated tbat patients
suffering from TMJ pain may benefit
from instruction in relaxation techniques
and coping skills. The literature suggests
that these therapies prevent relapses that
may occur with conventional therapy
alone (Orlando et al, 2007). However,
unfortunately these techniques are time-
consuming to teach and are not widely
available under the NHS.
Pharmacology
The two types of medication often
prescribed for the treatment of TMJ
problems are non-steroidal anti-
inflammatories (NSAIDs) and tricyclic
antidepressants. While there are few
randomized controlled trials to support
their use (Mujakperuo et al, 2010),
these medicines are often widely used
in specialist oral surgery departments
to treat TMJ problems that have been
resistant to other forms of treatment.
Acupuncture
Acupuncture is reported to be an
adjunctive treatment, producing a short-
term analgesic effect in patients with
painful TMJ symptoms (La Touche et
al, 2010) (see Figure 3). Again, accessing
these treatments under the NHS is often
difficult for patients—although, private
facilities do exist.
Other treatment options
Occlusal adjustment
and orthodontics
Occlusal adjustment is the selective
removal of enamel from the occlusal
contacts of teeth to increase the number of
Dental Nursing December 2011 Vol 7 No 12
clinical
KEY POINTS
• Temporomandibular joint
(TMJ) problems affect large
proportions of the population
at one time or other.
• Women are more likely to
suffer from TMJ problems
than men.
• TMJ problems often have
significant psychological,
as well as physical causes.
• Conservative management
should always precede
surgical intervention.
• No strong evidence exists
to suggest the single best
treatment for TMJ disorders.
Treatment planning should
involve balancing the patient's
wishes with potential risks
and benefits of treatment.
teeth in the intercuspal position. However,
a literature review concluded that occlusal
adjustment cannot be recommended for
the management or prevention of TMJ
problems (Koh and Robinson, 2003).
Similarly, a separate review found that
there is no evidence to show that active
orthodontic treatment can prevent or
relieve temporomandibular disorders
(Luther et al, 2010).
Hyaluronate
Hyaluronate is a gel-like glycosaminoglycan
that takes in water to ensure the resilience
of cartilage. Hyaluronate injections are
sometimes used for osteoarthritis of the
knees or hips, as it acts to cushion the
joint and reduces pain. However, reviews
of the evidence for its application in TMJ
problems found that there is currently
insufficient evidence to decide whether
it was beneficial for these patients (Shi et
al, 2003).
Botulinum toxin
In recent years, botulinum toxin or
Botox* has been used to treat TMJ pain
686
arising from myofacial pain dysfunction
syndrome. This involves the injection
of Botox" into masseter or temporalis
muscles and has been shown to increase
mouth opening and reduce pain (Freund
et al, 1999).
Arthroscopy and arthrocentesis
These treatments are medical procedures
usually undertaken under sedation
or general anaesthesia in a hospital
environment. They are similar procedures
that allow the removal of intracapsular
adhesions and delivery of the corticosteroid
betamethasone into the joint space. Both
treatments have the ability to reduce pain
and improve mouth opening. However,
when compared with arthroscopy, open
surgery has shown to be more effective
(Rigon et al, 2011).
Open surgery
Open surgery involves making larger cuts
in the skin to expose the TMJ. Procedures
include condylectomies (recontouring
the top of the condyle to reposition
the articular disc), articular eminence
recontouring (for individuals with
recurrent jaw dislocation) and partial or
total joint replacement; however, these
procedures are usually considered the
'last resort'.
Conclusion
The general dental team has a role
to play in the diagnosis, conservative
management and referral of patients
with TMJ pain. By understanding the
various causes and presentations of TMJ
problems it is possible to distinguish
between dental pain, TMJ disorder and
the more complicated facial pains to
ensure speedy diagnosis and management
for our patients. DN
Al-Ani M, Davies S, Gray R, Sloan P, Glenny
A (2004) Stabilisation splint therapy for
temporomandibular pain dysfunction syndrome.
Cochrane Datahase Syst Rev 1: CD002778
Berkovitz B, Moxham B, Sloan A (2011) Master
Dentistry. Vol 3. Oral biology. Churchill
Livingstone Elsevier, Edinburgh
Bertram S, Rudisch A, Innerhofer K, Pumpel E,
Grubwieser G, Emshoff R (2001) Diagnosing
TMJ internal derangement and osteoarthritis
with magnetic resonance imaging. ] Am Dent Ass
132(6): 753-61
Dahlstrom L, Carlsson G (2010) Temporomandibular
disorders and oral health-related quality of life. A
systematic review. Acta Odontol Scand 68(2):
80-5
Dimitroulis G (1998) Temporomandibular
disorders: a chnical update. Br Med J 317(7152):
190-4
Freund B, Schwartz M, Symington I (1999) The
use of botulinum toxin for the treatment ot
temporomandibular disorders: preliminary
fmdings. / Oral Maxillofac Surg 57(8): 916-21
Gonzalez Y, Schiffman E, Gordon S et al
(2011) Development of a brief and effective
temporomandibular disorder pain screening
questionnaire./Am Dent Ass 142(10): 1183-91
Gray R, Davies S, Quayle A ( 1994) A clinical approach
to mandibular disorders. 1. Classification and
functional anatomy Br Dent J 177(8): 429-35
Koh H, Robinson P (2003) Occlusal adjustment for
treating and preventing temporomandibular joint
disorders. / Oral Rehab 31(4): 287-92
La Touche R, Goddard G, De-La-Hoz J et al
(2010) Acupuncture in the treatment of pain
in temporomandibular disorders: a systematic
review and meta-analysis of randomized
controlled trials. Clin / Pain 26(6): 541-50
Luther E, Layton S, Mcdonald E (2010) Orthodontics
for treating temporomandibular joint (TMJ)
disorders. Cochrane Database Syst Rev 7:
CD006541
Mejersjö C, Hollender L (1984) Radiography of
the temporomandibular joint in female patients
with TMJ pain or dysfunction. Acta Radiol Diagn
25(3): 169-76
Mujakperuo H, Watson M, Morrison R, Macfarlane
T (2010) Pharmacological interventions for pain
in patients with temporomandibular disorders.
Cochrane Database Syst Rev 10: CD004715
Okeson J (1996) Guidelines for Assessment, Diagnosis,
and Management of Orofacial Pain. Quintessence
Publishing Co, Inc, Chicago
Orlando B, Manfredini D, Salvetti G, Bosco M (2007)
Evaluation of the effectiveness of biobehavioral
therapy in the treatment of temporomandibular
disorders: a literature review. Behav Med 33(3):
101-18
Rigon M, Pereira L, Bortoluzzi M, Loguercio A,
Ramos A, Cardoso J (2011) Arthroscopy for
temporomandibular disorders. Cochrane Database
Syst Rev 5: CD006385
Shi Z, Guo C, Awad M (2003) Hyaluronate for
temporomandibular joint disorders. Cochrane
Database Syst Rev 1: CD002970
Tasaki M, Westesson P, Isberg A, Ren Y, Tallents R
(1996) Classification and prevalence of
temporomandibular joint disk displacement
in patients and symptom-free volunteers. Am I
Orthod Dentofacial Orthop 109(3): 249-62
Wong K, Cheng J (2004) Recurrent dislocation of
temporomandibular joint treated by the dautrey
procedure - a case report and literature review.
Hong Kong Dent J 1(1): 31-4
Dental Nursing December 2011 Vol 7 No 12
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