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Temporomandibular Joint Syndrome

  • Author: Vivian Tsai, MD, MPH, FACEP; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Jul 08, 2016
 

Background

The temporal mandibular joint (TMJ) is the synovial joint that connects the jaw to the skull. These two joints are located just in front of each ear. Each joint is composed of the condyle of the mandible, an articulating disk, and the articular tubercle of the temporal bone. The movements allowed are side to side, up and down, as well as protrusion and retrusion. This complicated joint, along with its attached muscles, allows movements needed for speaking, chewing, and making facial expressions.

Pain and functional disturbances related to the TMJ are common.[1] Uyanik et al identifies the following three distinct causes of pain at the TMJ, which collectively fall under the broader term of TMJ syndrome[2] :

  • Myofascial pain dysfunction (MPD) syndrome, pain at the TMJ due to various causes of increased muscle tension and spasm. It is believed that MPD syndrome is a physical manifestation of psychological stress. No primary disorder of the joint itself is present. Pain is secondary to events such as nocturnal jaw clenching and teeth grinding. Treatment is focused on behavioral modification as opposed to joint repair.
  • Internal derangement (ID), where the problem lies within the joint itself, most commonly with the position of the articulating disc
  • Degenerative joint disease, where arthritic changes result in degeneration of the articulating surfaces
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Pathophysiology

The pathophysiology of TMJ syndrome is not entirely understood. It is believed that the etiology is likely multifactorial and arises from both local insults and systemic disorders. Local problems frequently arise from articular disc displacement and hereditary conditions affecting the structures of the joint itself, such as hypoplastic mandibular condyles. A study by Tallents et al found TMJ displacement in 84% of patients with symptomatic TMJ versus 33% of asymptomatic subjects.[3]

The TMJs can also be affected by conditions such as rheumatoid arthritis, osteoarthritis, and diseases of the articular disks. In addition, hypermobile TMJs, nocturnal jaw clenching, nocturnal bruxism, jaw clenching due to psychosocial stresses, and local trauma also play a significant role.

A study of 299 females aged 18-60 years suggests that compared with nonsmokers, female smokers younger than 30 years had a higher risk of temporomandibular disorder than older adults.[4]

As described by Hegde, a strong understanding of how the trigeminal nerve innervates the TMJ and surrounding structures explains the pain and referred pain patterns of TMJ disorders.[5] Irritation of the mandibular branch (V3) of the trigeminal nerve results in pain locally at the TMJ and also to other areas of V3 sensory innervation, which include the ipsilateral skin, teeth, side of the head, and scalp.

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Epidemiology

Frequency

United States

Currently, an estimated 10 million people have TMJ disorders, and roughly 25% of the population have symptoms at some point in their lives.

Mortality/Morbidity

The morbidity of the disorder is related to significant pain on movement of the jaw. While some patients' symptoms may resolve within weeks, others may have chronic symptoms that persist even with extensive therapy.

One study by Rammelsberg et al followed 235 patients over 5 years.[6] In this study, roughly one third of patients had completely resolved pain, one third had continuous pain over the 5 years, and one third had recurrent episodes with periods of remission.

Race-, Sex-, and Age-related Demographics

See the list below:

  • No apparent association with race exists.
  • Female-to-male ratio is roughly 4:1.
  • Highest incidence of TMJ syndrome is in adults aged 20-40 years
  • TMJ syndrome is found infrequently in the pediatric population
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Contributor Information and Disclosures
Author

Vivian Tsai, MD, MPH, FACEP Assistant Professor of Emergency Medicine, Mount Sinai School of Medicine, Queens Hospital Center

Vivian Tsai, MD, MPH, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

Steven M Heffer, MD Consulting Staff, Department of Emergency Medicine, Greenwich Hospital

Steven M Heffer, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

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.

Gino A Farina, MD, FACEP, FAAEM Professor of Emergency Medicine, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

Jerome FX Naradzay, MD, FACEP Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina

Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Joshua Parnes, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital Center

Disclosure: Nothing to disclose.

References
  1. Yule PL, Durham J, Wassell RW. Pain Part 6: Temporomandibular Disorders. Dent Update. 2016 Jan-Feb. 43 (1):39-42, 45-8. [Medline].

  2. Uyanik JM, Murphy E. Evaluation and management of TMDs, Part 1. History, epidemiology, classification, anatomy, and patient evaluation. Dent Today. 2003 Oct. 22(10):140-5. [Medline].

  3. Tallents, RH, Katzberg, RW, Murphy W, Proskin, et al. Magnetic resonance imaging findings in asymptomatic volunteers and symptomatic patients with temporomandibular disorders. J Prosthet Dent. 1996. 75:529. [Medline].

  4. Sanders AE, Maixner W, Nackley AG, Diatchenko L, By K, Miller VE, et al. Excess risk of temporomandibular disorder associated with cigarette smoking in young adults. J Pain. 2012 Jan. 13(1):21-31. [Medline]. [Full Text].

  5. Hegde V. A review of the disorders of the temporomandibular joint. J Indian Prosthodont Soc. 2005. 5:56-61.

  6. Rammelsberg P, LeResche L, Dworkin S. Longitudinal outcome of temporomandibular disorders: a 5-year epidemiologic study of muscle disorders defined by research diagnostic criteria for temporomandibular disorders. J Orofac Pain. 2003. 17(1):9-20. [Medline].

  7. Ahn SJ, Kim TW, Lee DY. Evaluation of internal derangement of the temporomandibular joint by panoramic radiographs compared with magnetic resonance imaging. Am J Orthod Dentofacial Orthop. 2006 Apr. 129(4):479-85. [Medline].

  8. American Academy of Family Physicians. Temporomandibular join (TMJ) pain. Am Fm Physician. 2007 Nov. 76(10):1483-4. [Medline].

  9. [Guideline] American Society of Temporomandibular Joint Surgeons. Guidelines for diagnosis and management of disorders involving the temporomandibular joint and related musculoskeletal structures. Cranio. 2003 Jan. 21(1):68-76. [Medline].

  10. Venezian GC, da Silva MA, Mazzetto RG, Mazzetto MO. Low level laser effects on pain to palpation and electromyographic activity in TMD patients: a double-blind, randomized, placebo-controlled study. Cranio. 2010 Apr. 28(2):84-91. [Medline].

  11. Silva PA, Lopes MT, Freire FS. A prospective study of 138 arthroscopies of the temporomandibular joint. Braz J Otorhinolaryngol. 2015 Jul-Aug. 81 (4):352-7. [Medline].

  12. Fricton JR, Look JO, Schiffman E, Swift J. Long-term study of temporomandibular joint surgery with alloplastic implants compared with nonimplant surgery and nonsurgical rehabilitation for painful temporomandibular joint disc displacement. J Oral Maxillofac Surg. 2002 Dec. 60(12):1400-11; discussion 1411-2. [Medline].

  13. Pharaboz C, Carpentier P. [MR imaging of the temporomandibular joints]. J Radiol. 2009 May. 90(5 Pt 2):642-8. [Medline].

 
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