1.5 Temporomandibular Joint Disorders
Key Features
After toothache, temporomandibular joint (TMJ) disorders are the most common cause of facial pain.
Most patients respond to conservative management.
Surgical treatments can repair or replace severe damage.
Disease of the temporomandibular joint (TMJ) is often classified as myogenous or arthrogenous, involving a primary problem of muscle tension versus joint anatomy. Patients present with pain, headache, discomfort with chewing, and popping of the TMJ.
Anatomy and Physiology
The TMJ connects the jaw and skull at the condyle of the mandible and the squamous portion of the temporal bone. The articular surface of the temporal bone is formed by the articular eminence anteriorly and the glenoid fossa posteriorly. The articular surface of the mandible consists of the top of the condyle. The surfaces are separated by an articular disk, the meniscus. The joint meniscus is made of fibrocartilage and is important for smooth joint function. The meniscus has a thick anterior band, a thin intermediate zone, and a thick posterior band; pathologic changes can contribute to TMJ disorders. A dense fibrous capsule surrounds the joint. Joint motion involves both a rotational component and a sliding translational component.
Epidemiology
TMJ disease is more common in women, with a female-to-male ratio of 4:1. The highest incidence is among young adults, aged 20 to 40 years. The disorder is seen more frequently in persons of European descent than in persons of African descent.
Clinical
Signs and Symptoms
Signs and symptoms include TMJ pain, earache, joint popping, joint locking, crepitus, tenderness, and spasm of the mastication muscles. Headache, neck ache, and tooth sensitivity are common. A history of poor sleep or other sleep disorders is common.
Differential Diagnosis
For patients presenting with complaints in the TMJ region, important considerations, in addition to TMJ disorders, include disease involving the ear, such as otitis externa or otitis media, and sources of referred otalgia such as malignancy of the larynx or pharynx. TMJ disorders may be related to rheumatoid arthritis, degenerative joint disease, ankylosis, dislocations, infections, congenital anomalies, and neoplasm. Dental malocclusion, jaw clenching, bruxism, increased pain sensitivity, and stress and anxiety should be considered. TMJ disorders may be mistaken for migraine, or these may be concurrent disorders.
Evaluation
History
As in other areas, a careful history is important to guide the clinical assessment. Particular attention to prior dental problems, dental procedures, and head and neck injuries is important. Prior diagnosis of psychologic disorders, chronic pain, migraine, or other headache disorders should be noted. A detailed, accurate medication list is required, with attention to chronic analgesic or anxiety medication use.
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