Temporomandibular Disorders – Diagnostic & Therapeutic
Ears, Eyes, Nose, and Throat, Inflammatory, Neurological, Orthopedic
- Temporomandibular disorders (TMD) = multiple categories of musculoskeletal and articular conditions.
- Affects 15% of adults:
- 20-40 years old
- Females > Males
- Patients typically experience pain in any of the following areas:
- Temporomandibular joint (TMJ)
- Mastication muscles
- Symptoms are generally self-limiting after an acute episode.
- 50 – 90% respond to conservative treatment.
- Some develop chronic TMD (= symptoms > 3 months duration).
- Diagnosis is commonly based on history and physical exam alone.
- Imaging may be useful if:
- Severe or refractory symptoms
- Unclear history and physical
- Facial pain (96%)
- Pain in TMJ or muscles of mastication associated with jaw movement
- +/- Radiation of pain to neck, ear etc.)
- Ear pain (82%) or tinnitus
- Headache (79%)
- Jaw discomfort/dysfunction (75%)
- Clicking, popping, crepitus in the jaw
- Habits (pencil biting, gum chewing)
- Tenderness of mastication muscles or TMJ
- Pain on biting down
- Abnormal or decreased jaw ROM (Normal is 35-55mm)
- Signs of teeth grinding/clenching
- Jaw malocclusion/deviation
- Transcranial and transmaxillary or panoramic Xray
- Initial screening modality
- Useful in evaluating:
- Degenerative articular disease
- Dynamic visualization of TMJ
- Can be used if MRI unavailable
- Subtle bone abnormalities
- Extensive joint evaluation
- Dental disorders
- Otologic disorders
- Trigeminal/glossopharyngeal/postherpetic neuralgia
- Head/neck cancer
- Headache syndromes
- Temporal arteritis/Giant cell arteritis
- History of malignancy/constitutional symptoms
- Temporal arteritis (Giant Cell Arteritis): Jaw claudication, unilateral headache, >50 years old
- Sensorimotor changes
- Conservative management is effective for the majority of patients.
- Pharmacologic management has insufficient evidence but is commonly used.
- Surgery can be considered for patients who do not respond to conservative management.
- Patient Education
- Natural course of TMD
- Reassurance and counseling
- Management of stress, habits, jaw rest
- Physical Therapy
- Active or passive activities to strengthen jaw muscle strength, relaxation, and ROM.
- Adjunctive short-term analgesic effect
- Dental devices/Occlusal splints
- Conflicting evidence
- Dental consultation on optimal device
- Naproxen 500 mg twice daily
- 10-14 days
- Muscle relaxant
- Can be combined with NSAIDs if muscular cause of TMD
- Cyclobenzaprine 5 mg daily at bedtime, titrate based on response up to 10 mg/day
- No more than 7 days
- Tricyclic antidepressants
- Used in chronic cases or persistent symptoms >2 weeks
- Nortriptyline 10 mg daily at bedtime, titrate at weekly intervals based on response up to 50 mg/day
- Up to 6-12 weeks for effect, 4 months total duration
- If effective over 4 months, taper off over 4-6 weeks
When to Refer
- Refer to oral and maxillofacial surgeon if:
- History of trauma/fracture to TMJ
- Severe pain/dysfunction unresponsive to conservative management
- Unidentifiable source of pain >3 months
- Refer to dentist if:
- Poor dental health
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Conflicting evidence exists for the effectiveness of any drug for treatment of TMD.
Non-pharmacological management of TMD has low risk of harm and has consensus in multiple reviews.
Mujakperuo, H. R., Watson, M., Morrison, R., & Macfarlane, T. V. (2010). Pharmacological interventions for pain in patients with temporomandibular disorders. The Cochrane database of systematic reviews, (10), CD004715.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated May 26, 2021
Visit our website at https://www.bcemergencynetwork.ca
Add public comment…