Elena Luiza Luca 1

Temporomandibular joint disorders

Elena Luiza Luca

1st Year, Group No. 2
School of Dental Medicine
Ovidius Constanta University

Temporomandib
ular joint
disorders

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Temporomandibular joint disorders

he temporomandibular joint (TMJ) acts like a sliding hinge,

connecting the jawbone to the skull. TMJ disorders can cause pain in
the jaw joint and in the muscles that control jaw movement.

The exact cause of a person's TMJ disorder is often difficult to determine.

The pain may be due to a combination of problems, such as arthritis or
jaw injury. Some people who have jaw pain also tend to clench or grind
their teeth, but many people habitually clench their teeth and never
develop TMJ disorders.
In most cases, the pain and discomfort associated with TMJ disorders can
be alleviated with self-managed care or nonsurgical treatments. Severe
TMJ disorders may require surgical repair.

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Temporomandibular joint disorders

Content
1.
What is the temporomandibular joint?
................... 4
2.
What are TMJ
disorders? ........................................ 5
3.
Causes ...............................................
................... 6
4.
Sings and
symptoms ..............................................
9
5.
Diagnosis ...........................................
................. 10
6.
How are TMJ disorders
treated? ............................ 11
7.
Research ............................................
................. 13
8.
Conclusion .
14
9.
References & Bibliography
15
10.

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Temporomandibular joint disorders

What is the temporomandibular joint?

The temporomandibular joint connects the lower jaw, called the
mandible, to the bone at the side of the headthe temporal bone. If
you place your fingers just in front of your ears and open your mouth,
you can feel the joints. Because these joints are flexible, the jaw can
move smoothly up and down and side to side, enabling us to talk,
chew and yawn. Muscles attached to and surrounding the jaw joint
control its position and movement.
When we open our mouths, the rounded ends of the lower jaw,
called condyles, glide along the joint socket of the temporal bone. The
condyles slide back to their original position when we close our
mouths. To keep this motion smooth, a soft disc lies between the
condyle and the temporal bone. This disc absorbs shocks to the jaw
joint from chewing and other movements.
The temporomandibular joint is different from the bodys other
joints. The combination of hinge and sliding motions makes this joint
among the most complicated in the body. Also, the tissues that make
up the temporomandibular joint differ from other load-bearing joints, like
the knee or hip. Because of its complex movement and unique
makeup, the jaw joint and its controlling muscles can pose a

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Temporomandibular joint disorders

tremendous challenge to both patients and health care providers when

problems arise.

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Temporomandibular joint disorders

What are TMJ disorders?

Disorders of the jaw joint and chewing musclesand how people

respond to themvary widely. Researchers generally agree that the
conditions fall into three main categories:

1. Myofascial pain involves discomfort or pain in the muscles that

control jaw function.

2. Internal derangement of the joint involves a displaced disc,

dislocated jaw, or injury to the condyle.

3. Arthritis refers to a group of degenerative/inflammatory joint

disorders that can affect the temporomandibular joint.

A person may have one or more of these conditions at the same

time. Some people have other health problems that co-exist with TMJ
disorders, such as chronic fatigue syndrome, sleep disturbances or
fibromyalgia, a painful condition that affects muscles and other soft

tissues throughout the body. These disorders share some common

symptoms, which suggests that they may share similar underlying

mechanisms of disease. However, it is not known whether they have a

common cause.

Rheumatic disease, such as arthritis, may also affect the

temporomandibular joint as a secondary condition. Rheumatic diseases

refer to a large group of disorders that cause pain, inflammation, and
stiffness in the joints, muscles, and bone. Arthritis and some TMJ

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Temporomandibular joint disorders

disorders involve inflammation of the tissues that line the joints. The
exact relationship between these conditions is not known.

How jaw joint and muscle disorders progress is not clear. Symptoms

worsen and ease over time, but what causes these changes is not

known. Most people have relatively mild forms of the disorder. Their
symptoms improve significantly, or disappear spontaneously, within
weeks or months. For others, the condition causes long-term,
persistent and debilitating pain.

Causes

Trauma to the jaw or temporomandibular joint plays a role in

some TMJ disorders. But for most jaw joint and muscle problems,
scientists dont know the causes. Because the condition is more
common in women than in men, scientists are exploring a possible link
between female hormones and TMJ disorders.

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Temporomandibular joint disorders

There are factors which appear to predispose to TMD (genetic,

hormonal, anatomical), factors which may precipitate it (trauma,
occlusal changes, parafunction), and also factors which may prolong it
(stress

and

again

parafunction). Overall,

two

hypotheses

have

dominated research into the causes of TMD, namely a psychosocial

model and a theory of occlusal dysharmony.
Disc displacement
In people with TMD, it has been shown that the lower head of
lateral pterygoid contracts during mouth closing (when it should relax),

and is often tender to palpation. To theorize upon this observation,

some have suggested that due to a tear in the back of the joint

capsule, the articular disc may be displaced forwards (anterior disc

displacement), stopping the upper head of lateral pterygoid from acting

to stabilize the disc as it would do normally. As a biologic

compensatory mechanism, the lower head tries to fill this role, hence

the abnormal muscle activity during mouth closure. There is some

evidence that anterior disc displacement is present in proportion of

TMD cases. Anterior disc displacement with reduction refers to

abnormal forward movement of the disc during opening which reduces

upon closing. Anterior disc displacement without reduction refers to an

abnormal forward, bunched-up position of the articular disc which does
not reduce. In this latter scenario, the disc is not intermediary between

the condyle and the articular fossa as it should be, and hence the

articular surfaces of the bones themselves are exposed to a greater

degree of wear (which may predispose to osteoarthritis in later life).

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Temporomandibular joint disorders

Degenerative joint disease

The general term "degenerative joint disease" refers to arthritis
(both osteoarthritis and rheumatoid arthritis) and arthrosis. The term
arthrosis may cause confusion since in the specialized TMD literature it

means something slightly different from in the wider medical literature.

In medicine generally, arthrosis can be a nonspecific term for a joint,

any disease of a joint (or specifically degenerative joint disease), and is

also used as a synonym for osteoarthritis. In the specialized literature

that has evolved around TMD research, arthrosis is differentiated from

arthritis by the presence of low and no inflammation respectively. Both

are however equally degenerative. The TMJs are sometimes described
as one of the most used joints in the body. Over time, either with

normal use or with parafunctional use of the joint, wear and

degeneration can occur, termed osteoarthritis. Rheumatoid arthritis,
an autoimmune joint disease, can also affect the TMJs.
Psychosocial factors
Emotional stress (anxiety, depression, anger) may increase pain
by causing autonomic, visceral and skeletal activity and by reduced
inhibition via the descending pathways of the limbic system. The

interactions of these biological systems have been described as a

vicious "anxiety-pain-tension" cycle which is thought to be frequently

involved in TMD. Put simply, stress and anxiety cause grinding of teeth
and sustained muscular contraction in the face. This produces pain

which causes further anxiety which in turn causes prolonged muscular

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Temporomandibular joint disorders

spasm at trigger points, vasoconstriction, ischemia and release of pain

mediators. The pain discourages use of the masticatory system (a

similar phenomenon in other chronic pain conditions is termed "fear

avoidance" behavior), which leads to reduced muscle flexibility, tone,

strength and endurance. This manifests as limited mouth opening and

a sensation that the teeth are not fitting properly.

Bruxism
Bruxism is an oral parafunctional activity where there is excessive

clenching and grinding of the teeth. It can occur during sleep or whilst

awake. The cause of bruxism itself is not completely understood, but

psychosocial factors appear to be implicated in awake bruxism

and dopaminergic dysfunction

and

other central

nervous

system mechanisms may be involved in sleep bruxism. If TMD pain

and limitation of mandibular movement are greatest upon waking, and
then slowly resolve throughout the day, this may indicate sleep
bruxism. Conversely, awake bruxism tends to cause symptoms that

slowly get worse throughout the day, and there may be no pain at all
upon waking.
The relationship of bruxism with TMD is debated. Many suggest
that sleep bruxism can be a causative or contributory factor to pain

symptoms in TMD. Indeed, the symptoms of TMD overlap with those of

bruxism. Others suggest that there is no strong association between

TMD and bruxism. A systematic review investigating the possible

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relationship concluded that when self-reported bruxism is used to

diagnose bruxism, there is a positive association with TMD pain, and

when more strict diagnostic criteria for bruxism are used, the
association with TMD symptoms is much lower. Self-reported bruxism
is probably a poor method of identifying bruxism. There are also very
many people who grind their teeth and who do not develop
TMD. Bruxism and other parafunctional activities may play a role in
perpetuating symptoms in some cases. Other parafunctional habits
such as pen chewing, lip and cheek biting (which may manifest

as morsicatio buccarum or linea alba), are also suggested to contribute

to the development of TMD. Other parafunctional activities might

include jaw thrusting, excessive gum chewing, nail biting and eating
very hard foods.

Trauma
Trauma, both micro and macrotrauma, is sometimes identified as

a possible cause of TMD; however, the evidence for this is not strong.

Prolonged mouth opening (hyper-extension) is also suggested as a

possible cause. It is thought that this leads to microtrauma and

subsequent muscular hyperactivity. This may occur during dental

treatment, with oral intubation whilst under a general anesthetic, during

singing or wind instrument practice (really these can be thought of as

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parafunctional activities). Damage may be incurred during violent

yawning, laughing, road traffic accidents, sports injuries, interpersonal
violence, or during dental treatment, (such as tooth extraction).

Hormonal factors
Since females are more often affected by TMD than males,
the female

sex

hormone estrogen has

been

suggested

to

be

involved. The results of one study suggested that the periods of highest

pain in TMD can be correlated with rapid periods of change in the

circulating estrogen level. Low estrogen was also correlated to higher
pain. In

the

menstrual

cycle,

estrogen

levels

fluctuate

rapidly

during ovulation, and also rapidly increases just before menstruation

and rapidly decreases during menstruation. Post-menopausal females

who are treated with hormone replacement therapy are more likely to
develop TMD, or may experience an exacerbation if they already had

TMD. Several possible mechanisms by which estrogen might be

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Temporomandibular joint disorders

involved in TMD symptoms have been proposed. Estrogen may play a

role in modulating joint inflammation, nociceptive neurons in the
trigeminal nerve, muscle reflexes to pain and -opioid receptors.

Signs and symptoms

A variety of symptoms may be linked to TMJ disorders. Pain,

particularly in the chewing muscles and/or jaw joint, is the most

common symptom. Other likely symptoms include:

radiating pain in the face, jaw, or neck,

jaw muscle stiffness,

limited movement or locking of the jaw,

painful clicking, popping or grating in the jaw joint when opening

or closing the mouth,

a change in the way the upper and lower teeth fit together.

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Temporomandibular joint disorders

Headache (possibly), e.g. pain in the occipital region (the back of

the head), or the forehead; or other types of facial pain

including migraine, tension headache. Or myofascial pain.

Pain elsewhere, such as the teeth, neck, or shoulder.

Diminished auditory acuity (hearing loss).

Tinnitus (occasionally).

Dizziness.

Sensation of malocclusion (feeling that the teeth do not meet

together properly).

Pain or feeling of pressure behind the eyes.

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Temporomandibular joint disorders

Diagnosis

There is no widely accepted, standard test now available to

correctly diagnose TMJ disorders. Because the exact causes and
symptoms are not clear, identifying these disorders can be difficult and
confusing.

Currently,

health

care

providers

note

the

patients

description of symptoms, take a detailed medical and dental history,

and examine problem areas, including the head, neck, face, and jaw.
Imaging studies may also be recommended.
You may want to consult your doctor to rule out other known
causes of pain. Facial pain can be a symptom of many conditions,
such as sinus or ear infections, various types of headaches, and facial
neuralgias (nerve-related facial pain). Ruling out these problems first
helps in identifying TMJ disorders.
Pain is the most common reason for people with TMD to seek

medical advice. Joint noises may require auscultation with

a stethoscope to detect. Clicks of the joint may also be palpated, over

the joint itself in the preauricular region, or via a finger inserted in the
external acoustic meatus, which lies directly behind the TMJ.

The differential diagnosis is with degenerative joint disease (e.g.

osteoarthritis),rheumatoid arthritis, temporal arteritis, otitis

media, parotitis, mandibular osteomyelitis, Eagle syndrome, trigeminal

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Temporomandibular joint disorders

neuralgia, oromandibular dystonia, deafferentation pains,

and psychogenic pain.

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Temporomandibular joint disorders

How are TMJ disorders treated?

Because

more

studies

are

needed

on

the

safety

and

effectiveness of most treatments for jaw joint and muscle disorders,

experts strongly recommend using the most conservative, reversible

treatments possible. Conservative treatments do not invade the tissues

of the face, jaw, or joint, or involve surgery. Reversible treatments do

not cause permanent changes in the structure or position of the jaw or

teeth. Even when TMJ disorders have become persistent, most

patients still do not need aggressive types of treatment.
Conservative Treatments

Because the most common jaw joint and muscle problems are

temporary and do not get worse, simple treatment may be all that is
necessary to relieve discomfort.

Self-Care Practices

There are steps you can take that may be helpful in easing symptoms,
such as:

eating soft foods,

applying ice packs,

avoiding extreme jaw movements (such as wide yawning, loud

singing, and gum chewing),

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Temporomandibular joint disorders

learning techniques for relaxing and reducing stress,

practicing gentle jaw stretching and relaxing exercises that may

help increase jaw movement. Your health care provider or a physical

therapist can recommend exercises if appropriate for your particular
condition.

Pain Medications

For many people with TMJ disorders, short-term use of over-the-

counter

pain medicines or

nonsteroidal

anti-inflammatory

drugs

(NSAIDs), such as ibuprofen, may provide temporary relief from jaw

discomfort. When necessary, your dentist or physician can prescribe

stronger pain or anti-inflammatory medications, muscle relaxants, or

anti-depressants to help ease symptoms.

Stabilization Splints

Your physician or dentist may recommend an oral appliance, also

called a stabilization splint or bite guard, which is a plastic guard that

fits over the upper or lower teeth. Stabilization splints are the most
widely used treatments for TMJ disorders. Studies of their effectiveness
in providing pain relief, however, have been inconclusive. If a

stabilization splint is recommended, it should be used only for a short

time and should not cause permanent changes in the bite. If a splint
causes or increases pain, or affects your bite, stop using it and see
your health care provider.

The conservative, reversible treatments described are useful for

temporary relief of pain they are not cures for TMJ disorders. If

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Temporomandibular joint disorders

symptoms continue over time, come back often, or worsen, tell your
doctor.
Botox

Botox (botulinum toxin type A) is a drug made from the same

bacterium that causes food poisoning. Used in small doses, Botox

injections can actually help alleviate some health problems and have
been approved by the Food and Drug Administration (FDA) for certain

disorders. However, Botox is currently not approved by the FDA for

use in TMJ disorders.

Results from recent clinical studies are inconclusive regarding the

effectiveness of Botox for treatment of chronic TMJ disorders.

Additional research is under way to learn how Botox specifically affects

jaw muscles and their nerves. The findings will help determine if this
drug may be useful in treating TMJ disorders.
Irreversible Treatments

Irreversible treatments that have not been proven to be effective

and may make the problem worse include orthodontics to change
the bite; crown and bridge work to balance the bite; grinding down

teeth to bring the bite into balance, called occlusal adjustment"; and
repositioning splints, also called orthotics, which permanently alter the
bite.

Surgery

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Other types of treatments, such as surgical procedures, invade

the tissues. Surgical treatments are controversial, often irreversible,
and should be avoided where possible. There have been no long-term
clinical trials to study the safety and effectiveness of surgical

treatments for TMJ disorders. Nor are there standards to identify

people who would most likely benefit from surgery. Failure to respond

to conservative treatments, for example, does not automatically mean

that surgery is necessary. If surgery is recommended, be sure to have
the doctor explain to you, in words you can understand, the reason for
the treatment, the risks involved, and other types of treatment that may
be available.

Implants

Surgical replacement of jaw joints with artificial implants may

cause severe pain and permanent jaw damage. Some of these devices
may fail to function properly or may break apart in the jaw over time. If

you have already had temporomandibular joint surgery, be very

cautious about considering additional operations. Persons undergoing
multiple surgeries on the jaw joint generally have a poor outlook for

normal, pain-free joint function. Before undergoing any surgery on the

jaw joint, it is extremely important to get other independent opinions
and to fully understand the risks.

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Temporomandibular joint disorders

Research
The National Institute of Dental and Craniofacial Research

(NIDCR), one of the National Institutes of Health (NIH), leads the

federal research effort on temporomandibular joint and muscle
disorders. In a landmark study, NIDCR is tracking healthy people over
time to identify risk factors that contribute to the development of these
conditions. Preliminary results from this study have identified a series

of clinical, psychological, sensory, genetic and nervous system factors

that may increase the risk of having chronic TMJ disorders. These new
findings expand our scientific understanding of the onset and natural

course of TMJ disorders and may lead to new diagnostic and treatment
approaches.

Additionally, researchers are using data from a TMJ implant

registry and repository that collected health information from patients

who received implants and from those who had implants removed.

Recent studies using the data have helped researchers plan for new
pain medication trials and other research projects.
PainStudies

Because pain is the major symptom of these conditions, NIH scientists

are conducting a wide range of studies to better understand the pain
process, including:

understanding the nature of facial pain in TMJ disorders and what

it may hold in common with other pain conditions, such as headache

and widespread muscle pain,

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Temporomandibular joint disorders

exploring differences between men and women in how they

respond to pain and to pain medications,

pinpointing factors that lead to chronic or persistent jaw joint and

muscle pain,

examining the effects of stressors, such as noise, cold and

physical stress, on pain symptoms in patients with TMJ disorders to
learn how lifestyle adjustments can decrease pain,

identifying medications, or combinations of medications and

conservative treatments, that will provide effective chronic pain relief,

investigating possible links between osteoarthritis and a history of

orofacial pain.

Replacement Parts

Research is also under way to grow human tissue in the

laboratory to replace damaged cartilage in the jaw joint. Other studies

are aimed at developing safer, more life-like materials to be used for

repairing or replacing diseased temporomandibular joints, discs, and

chewing muscles.

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Temporomandibular joint disorders

Conclusion

he challenges posed by TMJ disorders span the

research spectrum, from causes to diagnosis
through treatment and prevention. Researchers
throughout the health sciences are working
together not only to gain a better understanding of the
temporomandibular joint and muscle disease process,
but also to improve quality of life for people affected by
these disorders.

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Temporomandibular joint disorders

References & Bibliography

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

http://www.webmd.com/oralhealth/guide/temporomandibular-disorders-tmd?page=5

https://en.wikipedia.org/wiki/Temporomandibular_joint_dysfu
nction

http://www.nidcr.nih.gov/oralhealth/Topics/TMJ/TMJDisorder
s.htm#treated

http://www.mayoclinic.org/diseasesconditions/tmj/basics/lifestyle-home-remedies/con-20043566
http://www.nhs.uk/conditions/temporomandibular-jointdisorder/Pages/Introduction.aspx

http://www.evpdental.com.au/tooth-grinding-bruxism.html
http://www.facesny.com/temporomandibular-joint-surgery/
http://www.jamesislanddentists.com/treatments/biteadjustment/bruxism-treatments/

http://www.malonie.com/health/tmj/
http://www.qrclinicvancouver.com/conditionstreated/additional-information/tmj-treatment-moreinformation/