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Temporomandibular Disorders Clinical Presentation

  • Author: Charles F Guardia, III, MD; Chief Editor: Robert A Egan, MD  more...
 
Updated: Jan 07, 2014
 

History

A comprehensive, chronological history and physical examination of the patient, including dental history and examination, is essential to diagnose the specific condition to decide further investigations, if any, and to provide specific treatment.

  • Patients may have a history of heavy computer use as this has been found to be associated with development of TMD. [2]
  • About one third of patients have a history of psychiatric problems.
  • Patients may have a history of facial trauma, poor dental care, and/or emotional stress.
  • Patients with chronic eating disorders have a high prevalence of TMD.
  • Many patients with TMD also have neck and/or shoulder pain.
  • The practitioner should inquire about daytime or nighttime clenching. Daytime clenching has a stronger association with TMD than night time bruxism. [3]
  • A positive association may be observed between smoking and the occurrence of TMD in women younger than 30 years, although this association may be explainable by other factors (eg, stress levels). [4]
  • The patient may complain of any of the following symptoms:
    • Pain: Pain is usually periauricular, associated with chewing, and may radiate to the head but is not like a headache. It may be unilateral or bilateral in myofascial pain and dysfunction, and usually is unilateral in TMD of articular origin, except in rheumatoid arthritis. The pain is often described as a variable deep ache with intermittent sharp pain with jaw movement.
    • Click, pop, and snap: These sounds usually are associated with pain in TMD. The click with pain in anterior disk displacement is due to sudden reduction of the posterior band to normal position. An isolated click is very common in the general population and is not a risk factor for development of TMD.
    • Limited jaw opening and locking episodes: The lock can be open or closed; open lock is inability to close the mouth and is seen when the mandibular condyle dislocates anteriorly in front of articular eminence. Closed lock is an inability to open the mouth because of pain or disk displacement.
    • Headaches: The pain of TMD is not like a usual headache. The TMD may act as a trigger in patients prone to headaches. TMD involving muscle pain predisposes to migraines and chronic daily headaches and the more painful the TMD, the more likely it is to be associated with headache.[5] Some patients may have a history of headaches resistant to treatment; therefore, the TMD trigger should not be overlooked in such patients.[6]
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Physical

See the list below:

  • Observation
    • Forward head posture (this has been shown to displace the condyles posteriorly)
    • Jaw malocclusion, abnormal dental wear, and poor dentition
    • Visible clenching or spasm of the ipsilateral neck musculature
  • Examination
    • Joint range of motion: The examiner should evaluate jaw opening and closure as well as lateral deviation bilaterally. Normal range of motion for opening is 5 cm and lateral mandibular movement is normally 1 cm. Patients with TMD usually have reduced opening.
    • Palpation: The TMJ is best palpated laterally as a depression below the zygomatic arch and 1-2 cm anterior to the tragus. The posterior aspect of the joint is palpated through the external auditory canal. The joint should be palpated in both open and closed positions and also both laterally and posteriorly. While palpating, the examiner should feel for muscle spasm, muscle or joint tenderness, and joint sound. The muscles palpated as a part of complete TMJ examination are masseter, temporalis, medial pterygoid, lateral pterygoid, and sternocleidomastoid. In isolated myofascial pain and dysfunction, joint tenderness and joint click are usually absent.
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Causes

See the list below:

  • Myogenous TMD (myofascial pain and dysfunction)
    • Etiology is multifactorial and includes malocclusion, jaw clenching, bruxism, personality disorders, increased pain sensitivity, and stress and anxiety; in most patients more than one factor is present.
    • Significance of psychological factors has been recognized during the past few years.
    • Many patients also tend to score high on obsessive-compulsive scale and have increased levels of disease conviction
  • Arthrogenous TMD
    • Of the causes of arthrogenous TMD, disk displacement is the most common.
    • Other diseases such as degenerative joint disease, polyarthritides such as rheumatoid arthritis, ankylosis, dislocation, infection, neoplasia, and congenital anomalies may contribute to pain.

In 2005, The National Institute of Dental and Craniofacial Research (NIDCR) began a 7-year clinical study, the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) study, aimed at identifying risk factors for development of TMD. The study enrolls individuals who do not presently have TMD, and it will assess them by physical, psychological, and biochemical testing (including genetic screening) to determine the factors that lead to the development of TMD.

This study, with subsequent analysis of cohorts, has been published and has elucidated some factors appertaining to TMDs. There are genetic variants associated with TMDs, but no single nucleotide polymorphisms could be identified. Candidate gene associations with respect to nociception have been found and these include SCNA1 (voltage-gated sodium channel, type I, alpha subunit), ACE2 (angiotensin I-converting enzyme 2), MPDZ, (heat pain temporal summation with multiple PDZ domain protein), and APP (amyloid-beta precursor protein) Unfortunately, no causality has been firmly established.

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Contributor Information and Disclosures
Author

Charles F Guardia, III, MD Instructor in Neurology, Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth

Charles F Guardia, III, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Radiological Society of North America, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Robert A Egan, MD Director of Neuro-Ophthalmology and Stroke Service, St Helena Hospital

Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association

Disclosure: Received honoraria from Biogen Idec for speaking and teaching; Received honoraria from Teva for speaking and teaching.

Additional Contributors

Michael J Schneck, MD, MBA Vice Chair and Professor, Departments of Neurology and Neurosurgery, Loyola University, Chicago Stritch School of Medicine; Associate Director, Stroke Program, Director, Neurology Intensive Care Program, Medical Director, Neurosciences ICU, Loyola University Medical Center

Michael J Schneck, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Society of Neuroimaging, Stroke Council of the American Heart Association, Neurocritical Care Society

Disclosure: Received honoraria from Boehringer-Ingelheim for speaking and teaching; Received honoraria from Sanofi/BMS for speaking and teaching; Received honoraria from Pfizer for speaking and teaching; Received honoraria from UCB Pharma for speaking and teaching; Received consulting fee from Talecris for other; Received grant/research funds from NMT Medical for independent contractor; Received grant/research funds from NIH for independent contractor; Received grant/research funds from Sanofi for independe.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Arun Chaudhary, MD; Jeffrey Appelbaum, DO; and Jennifer Ault, DO, DPT to the development and writing of this article.

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