Temporomandibular dysfunction (TMD) describes pain originating in the temporomandibular joint (TMJ) or in the masticatory muscles, which arises from a variety of causes. This article is principally focused on the non-surgical treatment of TMD and evaluates the different options available. Interventions include self-care, pharmacological therapy, joint injections, trigger point injections, manual therapy, psychological therapies and occlusive splints. Simple self-care is often all that is required for minor acute cases, but a multi-modal and multi-disciplinary approach may be required for successful management in many cases.
A 52-year-old female administrator was seen in a general practice clinic complaining of a two-week duration of left ear pain but no popping, clicking, or locking. She otherwise felt well and denied any respiratory tract symptoms. She reported that prior to onset she had some minor dental treatment. She denied bruxism or any previous similar symptoms. There were no psychosocial issues elucidated.
On examination she had normal vital signs, her ear canals and tympanic membranes were normal, as was her throat, dentition, and nose. There were no cranial masses or cervical lymphadenopathy. She had active normal mouth opening distance with an S-curve opening indicating abnormal masticatory muscle control but there was no malocclusion. Passive motion testing caused pain in the left TMJ with associated hypomobility. She had tenderness of the left temporomandibular joint line with a positive joint compression test, as well as tenderness of the left masseter and temporalis. Examination of the cervical spine and cranial nerves were normal.
She was diagnosed with myogenic temporo-mandibular joint dysfunction, potentially due to the preceding dental treatment. An explanation was given, and she was reassured about the benign and normally self-limiting nature of the condition. She was instructed on self-care with the avoidance of unnecessary temporomandibular joint stress. On follow up four weeks later she reported that her pain had completely resolved. She still had an abnormal S-curve mouth opening but no further intervention was done due to the absence of symptoms. She was advised to return should she have further problems and explain to any future dentists about prior TMD.
Temporomandibular dysfunction (TMD), or otherwise termed the temporomandibular disorders(TMDs) are a heterogenous group of musculoskeletal disorders that affect 5-12% of the population. They are the second most common musculoskeletal complaint after low back pain. TMDs affect either the temporomandibular joint (TMJ) intracapsular structures (such as osteoarthritis, synovitis and disc displacement with and without reduction), the associated extracapsular masticatory musculature or both.
Three elements may be involved in TMD, namely specific TMJ problems, masticatory muscle dysfunction, and cervical spine dysfunction, and so the history and physical exam should be directed at this “triad.” Psychosocial factors should also be assessed as these are commonly present.
Symptoms include orofacial, jaw, neck, and head pain, reduced mouth opening, locking, malocclusion, clicking, and popping. Patients may also complain of otologic symptoms such tinnitus, dizziness, ear pressure or fullness, and hearing impairment. This is due to the shared trigeminal nerve innervation of the medial pterygoid and middle ear muscles, as well as the wrapping of the tensor tympani and tensor palati muscles around the hamulus notch of the maxilla.
Aetiology can be looked at in terms of predisposing, initiating, and perpetuating factors. Predisposing factors can be structural, metabolic, sex (more common in women), and age (more common under 55). Initiating (precipitating) factors includes trauma (both direct blows and indirect forces such as whiplash) and microtrauma (such as clenching or grinding). Perpetuating factors are maladaptive TMJ parafunctional habits, poor posture, poor sleep, and poor coping skills. Psychological factors have also been found to take part in either the principal cause or as a factor in chronicity.
Some controversial causes are bruxism, whiplash, and disc displacement. These conditions have not been clearly linked to pain due to them occurring in large numbers of the asymptomatic population. Indeed, most TMJ pathologies can exist with or without pain and dysfunction.
The evidence based diagnostic criteria and taxonomic classification of TMDs were standardised in the form of the research diagnostic criteria for temporomandibular disorders (RDC/TMD). See box 1 for a simplified classification of primary recurrent TMD. The RDC/TMD classification system is a useful starting point, but the clinician must be aware that causation is often multifactorial. The system also does not take into account the common presentation of co-existing cervical spine involvement, nor does it classify those with neuropathic pain or central sensitisation, however it does include psychosocial factors.
Simplified classification of primary recurrent TMD
|Box 1. Simplified classification of primary recurrent TMD
Disc displacement with and without reduction
The goals of treatment may include the reduction or elimination of jaw pain, while improving jaw and lifestyle function and reducing the need for future health care. For those with significant psychosocial stressors, addressing these factors should also be considered.
Self-care is often advised as a first line treatment modality. There is no accepted standard on what constitutes self-care, however it tends to include general advice about methods of reducing strain about the temporomandibular joint, addressing psychosocial stressors and providing individualised education. Presented in box 2 is a compilation of self-care advice elucidated from a variety of sources.
There is no literature to support the use of self-care over simple observation. Self-care is often used as the control group in studies of different intervention. These ‘control’ groups tend to have very high rates of improvement, such as a 57% reduction in pain in one study. An expert consensus group should define what constitutes self-care and then further study should be aimed at evaluating this intervention against no treatment (wait-list control).
|Box 2. Self-Care Approaches to Temporomandibular Dysfunction·
Medications are commonly used in TMD, however studies are of low quality.
If there are no contraindications, non-steroidal anti-inflammatory drugs (NSAIDs) can be trialled. One study showed no improvement with diclofenac, while another showed improvement with naproxen but not celecoxib. For TMJ synovitis a short course of steroids may be appropriate. The muscle relaxant cyclobenzaprine has also been studied, but this is not available in New Zealand.
For chronic pain, when the clinician suspects a central sensitisation process, low dose tricyclic antidepressants (TCAs) or gabapentinoids may be considered.
Propranolol (60mg extended released twice daily) has an NNT of 6.1 for a 50% reduction in TMJ pain after 9 weeks of treatment
Co-existent anxiety and depression is common in TMD, and selective serotonin reuptake inhibitors (SSRIs) are a treatment option, however there are reports of SSRI-induced bruxism.
Capsaicin is a commonly used topical analgesia, however it has not been found to be effective for TMD.
Trigger Point Injections
Although poorly understood, trigger points are often considered to be a characteristic feature of myofascial pain. Palpation of these points may bring about the patient’s familial pain and pain referral pattern suggesting that they may be clinically relevant for at least some patients with musculoskeletal disorders. Injection into these trigger points has been utilised across a wide range of musculoskeletal myofascial disorders including headaches and TMD with proven efficacy for many headache disorders.
The muscles usually injected in TMD are the temporalis and masseter as shown in figure 1. There may be clinically relevant trigger points in other surrounding muscles such as the frontalis, occipitalis, trapezius, levator scapula, sternocleidomastoid, semispinalis capitis, splenius cervicis, and trapezius which may also be injected.
- Figure 1. Trigger point injections in the temporalis and masseter as described by Robbins et al. Arrows show pain referral patterns, and dashed lines show pain destinations. The needles show common injection sites. The muscles can be located with gentle mouth opening and closing. For injections into the Occipitalis, Frontalis and Temporalis, the temporal artery must be located and then one finger placed over it, with the needle angled upwards to avoid puncture. Injection over three sites in the muscle may be required. For injection into the masseter, the needle is directly towards the posterior aspect of the ramus of the mandible.
Multiple injectable agents have been described and include local anaesthetics, corticosteroids, botulinum toxin, and dry needling. There is no strong evidence to support any one agent . Regardless, the use of local anaesthetic is the most commonly utilised in practice and in the literature. This is normally 1% lidocaine or 0.5% bupivacaine, however bupivacaine has a higher risk of myonecrosis. Injections are typically repeated monthly over several sessions.
The only true contraindication to local anaesthetic trigger point injections is allergy to the agent. Relative contraindications include vulnerability to vaso-vagal syncope, pregnancy (lignocaine is preferred), open skull defect, local or systemic infection, international normalised ratio (INR) over 3, and unclear anatomical landmarks.
After locating the injection sites, the site is marked by applying pressure to the area with a retracted ballpoint pen. The areas are then cleaned with an alcohol swab or similar. The size of the needle depends on the depth of the muscle and is normally between 21 to 27g. A no-touch technique is utilised by pulling the surrounding skin taut with two fingers. The area is then injected between the two fingers, 1-1.5cm away from the injection site and advanced at 30-degree angle aiming towards the trigger point. The area is then aspirated, confirming the absence of a vessel at the needle point, and 0.1-0.3mL is injected per trigger point. The needle may be reangled through the same puncture site for injection of other nearby trigger points. A total volume of 2 to 4mLs can be used per session.
- Main article: TMJ Injection
One study compared directly the intra-articular injection of hyaluronic acid versus the corticosteroid betamethasone for TMJ osteoarthritis. There was no placebo or self-care group. There was improvement in pain and function in both groups at six months, with a greater response in the hyaluronic acid group.
A typical protocol for these injections is 0.5mL of betamethasone or 0.5mL of hyaluronic acid injected into the upper joint space using the no-touch technique as described previously and then repeated one or two weeks later. Hyaluronic acid infiltrations (arthrocentesis) repeated five times over a period of several weeks is another technique shown to be effective in disc displacement without reduction.
Intraarticular dextrose prolotherapy (20%) repeated at 0, 1, and 2 months, has also been shown to have efficacy.
Manual therapy is a physical treatment used to treat a variety of musculoskeletal complaints. It is subdivided into joint based (joint manipulation and mobilisation), soft tissue massage (deep tissue, trigger point among others), and neural based techniques. There is limited evidence for its effectiveness across a variety of conditions. With regards to temporomandibular dysfunction, a systematic review in 2015 found that manual therapy was more effective than conservative treatment, resulting in improved mouth opening range of motion and decreased pain.
Joint mobilisation is a core manual therapy technique used to treat a variety of musculoskeletal disorders by reducing pain and increasing range of motion. The technique utilised is determined based on the identified joint restriction. It should be used with caution in those with hypermobility.
Taylor et al found in a small study that grade IV (small oscillatory movements at end range) mandibular mobilisation was effective for improving TMJ range of motion. The practitioner’s thumb is placed over the ipsilateral lower molars, with the remaining fingers wrapped around the mandible. A grade IV caudal distraction mobilisation is then performed, by taking the joint into resistance and then applying oscillatory downward pressure through the thumb. This is done for 60 seconds for a total of three sets, with 10 seconds rest in between (Figure 2).
- Figure 2. Positioning for mandibular distraction techniques. Note that the practitioner stands on the contralateral side, with the contralateral thumb pad applied to the lower molars, and the ipsilateral hand is monitoring the TMJ. The patient’s head is resting on the practitioner’s chest. This can also be performed with the patient prone.
A randomised controlled trial of those with TMD with disc displacement compared home mandibular distraction against splint therapy. There was improvement in both groups, but the exercise group had a statistically significant greater improvement in function. The exercise protocol was similar: there was an initial warmup with several small amplitude mouth opening and closing movements, followed by the patient pushing caudally on the mandibular teeth to the point of pain and then holding for 30 seconds for a total of 4 sets per day.
The jaw can also be mobilised in other ranges such as anteriorly, medially, laterally, and caudal-anterior-medial (CAM) depending on the located restriction. The principles remain the same as per the inferiorly directed technique. For the anterior glide, the thumb pulls the jaw anteriorly while the contralateral hand provides a posterior stabilisation force. With medial, lateral, and CAM mobilisation, the directional force is applied with the palm of the hand over the ramus of the jaw, while the contralateral hand provides a stabilisation force through the contralateral zygomatic arch.
Self-mobilisation with a medially directed force has been described by Shaffer et al to be a useful home exercise, and is summarised in figure 3.
- Figure 3. Self-mobilisation of the TMJ from Shaffer et al. In these home exercise examples, the large arrow signifies the application of a medially directed force through the mandibular ramus or condyle, while the contralateral hand applies a stabilisation force about the zygomatic arch. The technique is performed with both mouth-closed (left) and mouth-opened (right).
Mobilisation with Movement
Mobilisation with movement can also be performed to the TMJ. For example the clinician can perform an anteromedial glide of mandible on stabilised temporal bone with jaw opening. Ensure the glide pressure is applied close to the TMJ, not on the posterior aspect of the mandible.
Postural and other Therapeutic Exercises
Forward head posture is sometimes theorised to be a potential causative factor in TMD. The hypothetical basis is that forward head posture with rounded shoulders creates abnormal muscular balance and the translation of the mandibular postero-superiorly therefore causes increased pressure of the condyle onto the disc and glenoid fossa.
The Rocabado protocol (Figure 4) is a home exercise program, used in conjunction with self-care. It has the aim of improving postural position thereby restoring normal muscle and joint relationships. The program includes 6 exercises which are performed 6 times each and 6 times a day.
There have been conflicting results with regards to the efficacy of postural exercises. One randomised trial found it to be inferior to self-care, and showed that it did not in fact improve head posture. However another study showed the opposite conclusion with the superiority of postural exercises over self-care. More studies are likely needed in this area.
- Figure 4. The 6x6 Rocabado home exercise program.
There is no evidence that weak muscles are related to TMD, nor is there evidence to dictate which exercises are best. It is important to note that most patients with TMD over-activate their masticatory muscles and so relaxation techniques may in fact be more useful. This concept of the importance of muscle relaxation and the counterproductive effects of strengthening has been studied in other musculoskeletal disorders such as low back pain.
Intraoral myofascial therapy for myogenic TMD has been studied by Kalamir et al and shown to be more effective than wait list control and self-care. The treatment approach is summarised in Figure 5. The strength of the patient’s gag reflex limits utility. Extra-oral friction massage can also be useful when applied to the affected fibres of the temporalis muscle.
Sphenopalatine ganglion technique. The fifth finger is inserted along the buccal surface while the patient lightly occludes their teeth, moving slowly posteriorly until the sphenopalatine fossa is palpated. The patient then lifts their head off the table pressing into the examiner’s finger. This is repeated 3 times, then the patient relaxes onto the bed and gentle pressure is applied to the masseter and pterygoids. Ipsilateral eye watering may occur.
Cognitive behavioural therapy (CBT) is the most commonly used psychological approach for treating chronic pain, with its aim being to reduce maladaptive behaviour. Patients learn how their automatic thought processes contribute to their symptoms, how to challenge these thoughts, relaxation techniques, and discussion of fear-avoidance behaviour among other strategies. A Cochrane review assessing CBT for the treatment of chronic pain concluded that CBT compared to treatment as usual had weak effects on improving pain and disability and was effective at improving psychological outcomes.
Patients with TMD often have associated psychological symptoms and therefore CBT has been studied a treatment option. However, Liu et al in their meta-analysis found significant numerical inconsistencies in five of the trials they assessed, concluding that there is only weak evidence to support its implementation for the reduction in TMJ related pain and function. Pragmatically, as a minimally-invasive therapeutic option, CBT could be potentially be considered as an adjuvant therapy for when there are significant co-existent psychological factors.
Occlusion is the dental term for the bite. Many patients with TMD have poor occlusion, and it is theorised that this could be a contributing factor in some people to pain and disability due to the resulting imbalance in masticatory muscle activity. An occlusion splint, fitted by a dentist, is used at night and helps achieve an anatomically aligned disc-condyle position, thereby reducing this abnormal muscle activity (Figure 6).
Ebrahim et al in 2012 found low to moderate quality evidence for reduction in pain in their systematic review of 11 trials. Since that publication, a randomised trial in 2015 found no improvement in pain compared to counselling and masticatory muscle exercises at one year follow up. In addition an 8 year follow up trial published in 2013 found that more than 75% reported an improvement in TMJ pain, but there was no difference between the intervention and control groups. Owing to their cost and inconsistent evidence, it is the author’s view that occlusive splints should not be considered first line.
- Figure 6. Schematic of how an occlusion splint improves alignment of the TMJ. Image from BiteFx.
TMD is a common musculoskeletal complaint and can involve pain and dysfunction of the TMJ itself, the surrounding muscles, or both. Cervical spine dysfunction and psychosocial stressors are also often present.
The first line treatment is usually self-care. There are no trials assessing this intervention against waitlist control, however it is low risk and many patients improve spontaneously. If this is insufficient other non-surgical strategies may be considered. The interventions with the best evidence base include joint mobilisation, myofascial therapy, and injections. Larger studies are required to confirm previous findings. Other interventions to be considered with a mixed evidence base include pharmacological therapy, home exercises, occlusive splints, and psychological therapies. Access to these interventions will depend on local expertise and cost.
Ultimately the clinician will be guided by their clinical assessment and may utilise multiple treatment modalities to improve pain and function.
This article is based off Jeremy Steinberg's MSM709 university essay.
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