• 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:
  • Jaw
  • Temporomandibular joint (TMJ)
  • Mastication muscles
  • Ear
• 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

History

• 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)

Physical

• 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

Imaging

• Transcranial and transmaxillary or panoramic Xray
  • Initial screening modality
  • Useful in evaluating:
    • Fractures
    • Dislocations
    • Degenerative articular disease
  • Ultrasound
    • Dynamic visualization of TMJ
    • Can be used if MRI unavailable
  • CT
    • Subtle bone abnormalities
  • MRI
• Extensive joint evaluation

Differential Diagnoses

• Dental disorders
• Otologic disorders
• Trigeminal/glossopharyngeal/postherpetic neuralgia
• Head/neck cancer
• Headache syndromes
• Temporal arteritis/Giant cell arteritis

Red Flags

• History of malignancy/constitutional symptoms
• Lymphadenopathy/masses
• 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.

Non-Pharmacological

• 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.
  • Acupuncture
    • Adjunctive short-term analgesic effect
  • Dental devices/Occlusal splints
    • Conflicting evidence
    • Dental consultation on optimal device

Pharmacological

• NSAIDs
  • 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
  • Malocclusion

1. 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. 

   
   

2. Gauer, R. L., & Semidey, M. J. (2015). Diagnosis and treatment of temporomandibular disorders. American family physician, 91(6), 378–386.

   
   

3. Mehta, N.R., & Keith, D. (2021). Temporomandibular disorders in adults. In L. Kunins (Ed.), Retrieved May 6, 2021, from UpToDate.com.

   
   

4. Durham, J., Newton-John, T. R., & Zakrzewska, J. M. (2015). Temporomandibular disorders. BMJ (Clinical research ed.), 350, h1154. 

   
   

5. Scrivani, S. J., Keith, D. A., & Kaban, L. B. (2008). Temporomandibular disorders. The New England journal of medicine, 359(25), 2693–2705.