Temporomandibular Syndrome

What is Temporomandibular Syndrome?

Temporomandibular disorder (TMD) is a term for various conditions that affect the face and mouth area, including the chewing muscles and the hinge joint connecting the jawbone to the skull, called the temporomandibular joint (TMJ). Common signs of TMD include pain in the TMJ, limited jaw movement, and noises coming from the TMJ.

The temporomandibular joint is a complex joint, kind of like a door hinge and sliding joint all in one, formed by a part of the skull called the temporal bone and the rounded top edge of your jawbone, or mandible. It is separated by a disc into two compartments, both filled with a lubricating fluid called synovial fluid. The upper compartment allows for gliding or sliding movement, while the lower one enables hinge or rotational movement.

The muscles affected in TMDs are the muscles we use for chewing: the temporalis, masseter, and both the medial and lateral pterygoid muscles. The TMJ is kept stable by three main ligaments: the temporomandibular, stylomandibular, and sphenomandibular ligaments.

Blood flow to the TMJ mainly comes from offshoots of an artery on the side of the neck called the external carotid artery. A few other branches also contribute. The feeling or sensation in the TMJ is supplied by the auriculotemporal and masseteric branches of the mandibular nerve (V3), itself a branch of a major facial nerve known as the trigeminal nerve.

What Causes Temporomandibular Syndrome?

Temporomandibular joint disorders (TMD) are not fully understood yet, but are likely to have several different causes. Knowing what these causes might be can help with managing the condition.

There are two major types of TMD, each with different potential causes. One type is ‘myofascial’ TMD. This means that the condition primarily affects the muscles involved in chewing, which may become tense, tired, and painful. Many factors can contribute to this muscle dysfunction, such as stress, teeth grinding and abnormal posture, mental health conditions like depression and anxiety, and auto-immune diseases. Chronic pain conditions like fibromyalgia are also often connected to TMD.

The other type is ‘intraarticular’ TMD, which involves issues within the joint itself. The most common cause is when the disc inside the joint goes out of place. Other possible causes of this type include injury, inflammation in the joint, osteoarthritis, joint hypermobility, and inflammatory diseases like rheumatoid arthritis. It’s still unclear whether an improper alignment of the teeth (‘malocclusion’) might contribute to TMD.

Risk Factors and Frequency for Temporomandibular Syndrome

Temporomandibular joint disorder (TMD) can develop at any age, but it’s most commonly seen in adults between 20 to 40 years old. It’s more likely to affect women than men, although we’re not sure why. Despite signs of this disorder appearing in 60 to 70% of people, only about 5% to 12% of those people actually experience symptoms severe enough to need treatment.

TMD can develop at any age, but is most common in adults aged 20 to 40.
Women are more likely to be affected by TMD than men.
While 60 to 70% of people show signs of TMD, only 5% to 12% have symptoms that need treatment.

Signs and Symptoms of Temporomandibular Syndrome

When checking for Temporomandibular disorder (TMD), health professionals need to take careful note of a patient’s medical and dental background. They will pay special attention to details about any pain, including where it’s located, when it started, and its characteristics. They will also ask about what makes the pain better or worse, previous treatments, and any history of other pain conditions.

Symptoms that may point to TMD vary. They can include pain, a clicking or crackling sound in the jaw, and limited movement of the jaw. The pain is usually triggered by jaw movement. Pain that occurs spontaneously could hint at a different cause. The pain can also spread to the neck and scalp, and may get worse when chewing, yawning, or talking for a long time. A popping sound when opening or closing the mouth could mean the disc at the front of the jaw is displaced or arthritis is present.

People with TMD often have other symptoms like headaches and ear-related issues like ear pain, ringing in the ears, dizziness, a feeling of fullness in the ears, and the sense that their hearing is impaired. These ear symptoms are more common in people with muscle-related disorder. This could be because certain structures in the middle ear and chewing muscles share the same origin in the embryo.

During a physical check-up, the professional will also pay special attention to signs of tooth wear, abnormal jaw movements, tenderness in the chewing muscles as well as neck and shoulder, pain when the jaw is loaded, and irregular posture. They will check if the cranial nerves are functioning properly. They will also feel the muscles used for chewing and around the neck to detect any trigger points, muscle spasms, and referred pain.

Pain in the TMJ and the muscles used for chewing is a common issue. The patient might feel a continuous or intermittent dull ache over the TMJ, the ear, or the temporal fossa, and it is often noticeable during jaw movement or when touching the affected areas. This pain can be caused by mechanical trauma or muscle exhaustion. Pain from within the joint comes from overuse, damage, or degenerative changes of the joint and its surrounding tissues.

Usually the joint will make clicking or crackling sounds. Clicking indicates uncoordinated movement between the head of the lower jawbone and the articular disc. Crepitations are complex sounds caused by uneven, coarse joint surfaces during jaw movement.

Limited jaw movement can happen when the person tries to open, close, thrust forward, or move the jaw side to side. This can arise from tension in the muscles or ligaments, or disc displacement.

Dislocation happens when the head of the lower jawbone moves out of the socket, leading to an inability to close the mouth. The patient can usually correct this himself, or he might need a medical professional to do it.

In relation to ear-related symptoms, TMJ pain at the back of the ear region tends to be more noticeable. Ringing in the ears, ear itching, and dizziness are other common symptoms associated with joint pain.

Patients might interpret the pain and soreness from the muscles used to chew along the temples as headaches. This kind of pain can also occur with other types of headaches like migraines.

Testing for Temporomandibular Syndrome

If you have pain when you move your jaw, headaches, and feel pain in areas other than where the pain originates (referred pain), this could suggest a muscle-related cause. If you feel tenderness when touching the jaw joint (TMJ) and hear joint sounds, this could suggest a problem within the jaw joint. To rule out other causes of facial pain, a medical professional might look inside your mouth, check the inside of your ear, and feel the muscles in your neck.

For a detailed look at the TMJ, magnetic resonance imaging (also known as a MRI) is usually the preferred method. This is because MRIs can accurately show if there is fluid in the joint, if the disc in the joint has moved from its normal position, and the state of the soft tissues. However, a simple X-ray that shows a wider view of the face and jaw (panoramic X-ray) is usually the first test done. It’s a quick way to check the state of your teeth and jaw joint. Other types of X-rays and CT scans can show severe joint degradation, fractures, and dislocations.

An ultrasound test can show the disc position. However, it won’t be very helpful in diagnosing osteoarthritis, a type of joint disease. Computed tomography (CT) scans and MRI scans can provide more help in serious cases, or when there’s suspicion of abnormalities in the structure of the jaw joint.

In addition to these tests, new techniques such as nerve blocks, injecting a type of bacteria into muscles (botulinum toxin injections), arthrography which is a type of imaging used to help see joints, and gathering data on jaw movement may be useful in helping to diagnose the problem.

Treatment Options for Temporomandibular Syndrome

Conservative treatment, sometimes referred to as non-surgical or non-invasive treatment, is often the first approach used when managing TMD — a condition that affects the jaw joint and muscles. These methods can reduce symptoms in 50 to 90% of patients and typically include reassuring the patient and educating them about the condition, suggesting a soft diet and rest for the jaw, applying warm compresses to the painful area, and recommending passive stretching exercises. However, the effectiveness of using dental devices like occlusal and non-occlusal splints (devices to reduce teeth grinding) for treating TMD is still uncertain and based on limited evidence.

Moving on to behavioral changes, because your muscle activity can change due to emotional stress, managing your stress levels becomes vital if you have TMD. Improving your sleep hygiene, reducing stress, and treating parafunctional habits (which are unusual habits that could affect your jaw like grinding teeth) can immensely improve TMD symptoms. Techniques like cognitive-behavioral therapy, aimed at changing your thought habits and behavior, can also provide both short-term and long-term help.

Furthermore, increasing patients’ awareness around the connection between muscle hyperactivity and stress can lead to better treatment adherence, improved mental health, and better management of TMD. Some of the strategies include restricting the movement of the jaw within a pain-free range to manage pain and enhance psychological health, and reducing the time your teeth are in contact, except during eating, swallowing, and speaking. This can be taught by your healthcare provider and a simple exercise like “lip puffing” can help disengage your teeth, reducing pain and discomfort.

Physiotherapy techniques, like stretching exercises and postural training, can improve the jaw’s range of movement, though may not always alleviate pain. Additional physical treatments may include thermotherapy (heat therapy), ultrasound, electro galvanic stimulation, and cold laser.

In terms of medication, nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first line of treatment for TMD. In cases of repeated jaw muscle spasms and teeth grinding, a type of medication called benzodiazepines might be used if relaxation techniques aren’t working. For other pain disorders, tricyclic antidepressants may be tried out to see if they alleviate TMD symptoms.

Invasive procedures, such as steroid, hyaluronic acid, and botox injections into the jaw joint, may be recommended if the more conservative treatments mentioned above don’t help or if the TMD symptoms are particularly severe. However, repeated corticosteroid injections could damage the joint cartilage, and there’s limited evidence supporting the use of hyaluronic acid injections for sudden severe symptoms. Botox injections may help treat painful trigger points and chronic teeth grinding, but the available research for its use in treating chronic muscle pain is still inconclusive.

Several other conditions can cause facial and ear pain, as well as headaches. These should also be considered when trying to diagnose temporomandibular disorders (TMDs).

Here are some common causes:

Facial pain: This could be due to trigeminal, glossopharyngeal, and post-herpetic neuralgia, sinusitis, issues with the salivary glands, or carotidynia.
Orofacial pain: This is often due to dental problems, such as cavities, abscesses or tooth eruptions.
Headaches: The cause of headaches can often be migraines, cluster headaches, or temporal arteritis.
Ear pain or a feeling of pressure: Some common causes include middle ear infections, injuries, barotrauma or problems with the Eustachian tube.

What to expect with Temporomandibular Syndrome

Approximately 40% of patients indicate that their symptoms improve without any medical intervention. Moreover, most patients respond well to conservative treatments. However, a small percentage of patients may experience persistent or ongoing Temporomandibular Joint Disorder (TMD). Currently, there are no known risk factors connected with chronic TMD. Nevertheless, recent research has found a correlation between the presence of chronic TMD pain and increased levels of sympathetic nervous system activity, often referred to as heightened sympathetic tone.

Possible Complications When Diagnosed with Temporomandibular Syndrome

The classic trio of symptoms for temporomandibular disorder involve pain in the jaw joint, limited jaw movement, and noticeable clicking with mouth movements. These symptoms can make everyday actions like eating, talking, or yawning challenging and have a major effect on a person’s quality of life.

Common Symptoms:

Pain in the jaw joint
Limited jaw movement
Clicking sound during mouth movements
Difficulties performing everyday tasks such as eating, talking or yawning

Preventing Temporomandibular Syndrome

Teaching the patient is a very important part of treating conditions related to the temporomandibular joint, which connects the jawbone to the skull. This will be discussed more thoroughly in the part of the article that talks about treatment and management.

Frequently asked questions

Temporomandibular Syndrome (TMD) is a term for various conditions that affect the face and mouth area, including the chewing muscles and the hinge joint connecting the jawbone to the skull, called the temporomandibular joint (TMJ).

60 to 70% of people show signs of TMD, but only 5% to 12% have symptoms that need treatment.

Signs and symptoms of Temporomandibular Syndrome (TMD) include: - Pain in the jaw, which is usually triggered by jaw movement. Spontaneous pain could indicate a different cause. - Clicking or crackling sound in the jaw during movement. - Limited movement of the jaw, making it difficult to open, close, thrust forward, or move the jaw side to side. - Pain that can spread to the neck and scalp, and worsen when chewing, yawning, or talking for a long time. - Popping sound when opening or closing the mouth, which could indicate a displaced disc or arthritis. - Other symptoms like headaches, ear pain, ringing in the ears, dizziness, a feeling of fullness in the ears, and impaired hearing. - Tooth wear and abnormal jaw movements. - Tenderness in the chewing muscles, neck, and shoulder. - Pain when the jaw is loaded. - Irregular posture. - Dysfunction of the cranial nerves. - Trigger points, muscle spasms, and referred pain in the muscles used for chewing and around the neck. - Continuous or intermittent dull ache over the TMJ, ear, or temporal fossa, especially during jaw movement or when touching the affected areas. - Clicking or crackling sounds in the joint during movement. - Limited jaw movement due to muscle tension, ligament tension, or disc displacement. - Dislocation of the lower jawbone, leading to an inability to close the mouth. - TMJ pain at the back of the ear region. - Ear-related symptoms such as ringing in the ears, ear itching, and dizziness. - Pain and soreness in the muscles used to chew along the temples, which can be mistaken for headaches.

Temporomandibular Syndrome (TMD) can have several different causes. The two major types of TMD are myofascial TMD, which primarily affects the muscles involved in chewing, and intraarticular TMD, which involves issues within the joint itself. Some potential causes of myofascial TMD include stress, teeth grinding, abnormal posture, mental health conditions, autoimmune diseases, and chronic pain conditions like fibromyalgia. Possible causes of intraarticular TMD include disc displacement, injury, inflammation in the joint, osteoarthritis, joint hypermobility, and inflammatory diseases. It is still unclear whether an improper alignment of the teeth (malocclusion) might contribute to TMD.

Trigeminal neuralgia, glossopharyngeal neuralgia, post-herpetic neuralgia, sinusitis, issues with the salivary glands, carotidynia, dental problems (such as cavities, abscesses, or tooth eruptions), migraines, cluster headaches, temporal arteritis, middle ear infections, injuries, barotrauma, and problems with the Eustachian tube.

The types of tests that may be ordered to properly diagnose Temporomandibular Syndrome (TMD) include: 1. Panoramic X-ray: This is usually the first test done to check the state of the teeth and jaw joint. 2. Magnetic Resonance Imaging (MRI): Provides a detailed look at the TMJ and can accurately show if there is fluid in the joint, if the disc has moved from its normal position, and the state of the soft tissues. 3. Computed Tomography (CT) scan: Can show severe joint degradation, fractures, and dislocations. 4. Ultrasound: Can show the position of the disc, but not helpful in diagnosing osteoarthritis. 5. Other types of X-rays and CT scans: Can provide more help in serious cases or when there's suspicion of abnormalities in the structure of the jaw joint. 6. Nerve blocks, botulinum toxin injections, arthrography, and gathering data on jaw movement may also be useful in diagnosing the problem.

Temporomandibular Syndrome (TMD) is often treated with conservative methods as the first approach. These methods include reassuring and educating the patient, suggesting a soft diet and rest for the jaw, applying warm compresses, and recommending passive stretching exercises. However, the effectiveness of dental devices like occlusal and non-occlusal splints is uncertain. Behavioral changes such as managing stress, improving sleep hygiene, and treating parafunctional habits can greatly improve TMD symptoms. Physiotherapy techniques like stretching exercises and postural training can improve jaw movement. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used as the first line of medication, and in severe cases, invasive procedures like injections may be recommended. However, the evidence for some of these treatments is limited.

The text does not mention any specific side effects when treating Temporomandibular Syndrome (TMD). However, it does mention that repeated corticosteroid injections could potentially damage the joint cartilage, and there is limited evidence supporting the use of hyaluronic acid injections for sudden severe symptoms. Additionally, the available research for the use of Botox injections in treating chronic muscle pain is still inconclusive. It is important to consult with a healthcare provider to discuss the potential risks and benefits of different treatment options for TMD.

Approximately 40% of patients indicate that their symptoms improve without any medical intervention. Most patients respond well to conservative treatments. However, a small percentage of patients may experience persistent or ongoing Temporomandibular Joint Disorder (TMD).

A dentist or a maxillofacial surgeon.

Joint Muscle and Bone Restricted Mandibular Movement Temporomandibular Joint Crepitus Temporomandibular Joint pain