Temporomandibular Joint Dysfunction

THE CLINICAL SYNDROME

Temporomandibular joint dysfunction (TMD) (also known as myofascial pain dysfunction of the muscle of mastication) is characterized by pain in the joint itself that radiates into the mandible, ear, neck, and tonsillar pillars. Headache often accompanies the pain of TMD and is clinically indistinguishable from the pain of tension-type headache. Stress often is the precipitating or exacerbating factor in the development of TMD. Dental malocclusion may play a role in the evolution of TMD. Internal derangement and arthritis of the temporomandibular joint may present as clicking or grating when the joint is opened and closed. Untreated, the patient may experience increasing pain in the aforementioned areas and limitation of jaw movement and opening.

Stress is often a trigger for TMD.

SIGNS AND SYMPTOMS

The temporomandibular joint is a true joint that is divided into an upper and lower synovial cavity by a fibrous articular disk. Internal derangement of this disk may result in pain and TMD, but extracapsular causes of temporomandibular joint pain are much more common. The joint space between the mandibular condyle and the glenoid fossa of the zygoma may be injected with small amounts of local anesthetic and steroid. The temporomandibular joint is innervated by branches of the mandibular nerve. The muscles involved in TMD often include the temporalis, masseter, external pterygoid, and internal pterygoid and may include the trapezius and sternocleidomastoid. Trigger points may be identified when palpating these muscles. Crepitus on range of motion of the joint is suggestive of arthritis rather than of dysfunction of myofascial origin. A history of bruxism and/ or jaw clenching is often present.

TREATMENT

The mainstay of TMD is the combination of pharmacological treatment with tricyclic antidepressants, physical modalities such as oral orthotic devices and physical therapy, and intra-articular injection of the joint with small amounts of local anesthetic and steroid. Antidepressant compounds such as nortriptyline at a single bedtime dose of 25 mg will help normalize sleep disturbance and treat underlying myofascial pain syndrome. Orthotic devices help the patient avoid jaw clenching and bruxism, which may exacerbate the clinical syndrome. Intra-articular injection is useful to provide palliation of acute pain to allow physical therapy as well as to treat joint arthritis that may contribute to the patient’s pain symptomatology and joint dysfunction. Rarely, surgical treatment of the displaced intra-articular disk is required to restore the joint to normal function and to reduce pain.

For intra-articular injection of the temporomandibular joint, the patient is placed in the supine position with the cervical spine in the neutral position. The temporomandibular joint is identified by asking the patient to open and close the mouth several times and palpating the area just anterior and slightly inferior to the acoustic auditory meatus. After the joint is identified, the patient is asked to hold his or her mouth in neutral position. Injection of the joint may be repeated in 5- to 7-day intervals if the symptoms persist.

Correct needle placement for injections of the temporomandibular joint.

Pain from TMD requires careful evaluation to design an appropriate treatment plan. Infection and inflammatory causes including collagen vascular diseases must first be ruled out. When temporomandibular joint pain occurs in older patients, the pain must be distinguished from the jaw claudication associated with temporal arteritis. Stress and anxiety often accompany TMD, and these factors must be addressed and managed. The myofascial pain component of TMD is best treated with the tricyclic antidepressant compounds, such as amitriptyline. Dental malocclusion and nighttime bruxism should be treated with an acrylic bite appliance. Narcotic analgesics and benzodiazepines should be avoided in patients suffering from TMD.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue .Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age –related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.