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Temporomandibular Dysfunction Research Review

Introduction & Etiology

Temporomandibular Joint Disorder (TMD) describes a complex group of muscular and articular disorders affecting the TMJ, leading to pain, dysfunction, and eventually degeneration.

Most causes of TMD can be divided into either myogenous (muscular) or arthrogenous (articular). TMD of myogenous origin is more common (1) and may arise from muscular hypertonicity, trigger points, fascial restrictions, and/or functional muscle imbalance of the muscles of mastication. One of the most commonly involved muscles is the masseter. Other recognized triggers for myogenous TMD include bruxism, clenching, cervicocranial dysfunction (2), postural syndromes, especially a forward head posture (3,4,100), and trauma (5). TMD symptoms may occur in up to one-third of those patients involved in a whiplash injury. (6).

Disk displacement and osteoarthritis are common causes for TMD of arthrogenous origin. Other causes of TMD of articular origin include loose bodies, inflammatory arthropathy, trauma, mandibular fracture, dislocation, malocclusion, infection, and neoplasm. In TMD of articular origin, muscular dysfunction is secondary.

Studies vary on the relationship of premolar extraction to the development of TMD (7). Still, a systematic review suggests that the third molar location, degree of impaction, and subsequent extraction are associated with the development of TMD. (57). Nail biting, grinding of teeth, biting of lips, mouth breathing, and playing a musical instrument are significantly associated with TMD symptoms. (39,86) Being overweight or having poor physical fitness are known risk factors for TMD symptoms. (82) Sleeping less than 5 hours or greater than 9 hours each night is associated with an increased rate of TMD. (80,89) The incidence of TMD is higher in patients with untreated sleep apnea. (77) Age and Previous Orthodontics treatment have not been linked to TMD. (106)

Psychosocial disturbances, including stress and depression, are another widely recognized co-morbidity for TMD. (46,81,84,93,110,113) Stress alone has been identified as the most significant factor in developing TMD. (99) TMD patients with PTSD report a nearly four-fold increase in pain as compared to subjects without PTSD. (42) Patients with polycystic ovary syndrome are nearly seven times more likely to suffer from TMD. (69) Ankylosing spondylitis patients have a nearly three-fold increased risk. (85,90,120) TMD patients have an elevated incidence of suffering from migraine headaches. (59)

Estimates for the incidence of TMD vary between 4-31% (8,9,73). Up to 3% of Americans seek treatment for TMD each year (21). At presentation, most patients are 20-50 years old, and prevalence is 2-3 times higher in females. Patients with rheumatoid arthritis have a higher incidence of TMD. (60,73)

Clinical Presentation

Typical symptoms include clicking or crepitus, restricted opening, transient locking, and pain. Symptoms may be exacerbated by mastication. TMD pain is generally described as an “ache” located immediately anterior to the ear canal but may refer to other areas of the face, head, neck and shoulders. (6) Spinal pain and tenderness are common concurrent findings in TMD patients. (43,45) Up to half of TMD patients concurrently suffer from neck pain and headaches, suggesting a common link arising from the upper cervical spine. (10,37,74,88,101,102) Decreased glenoid fossa depth may be associated with an increased incidence of tinnitus in TMD patients due to their close anatomical relationship. (104) In addition to tinnitus, other otologic signs/symptoms include ear fullness, otalgia, vertigo, or hearing loss. These symptoms occur with TMD concurrently 85–95% of the time. (115) Patients with chronic TMD frequent stomach pain has been observed. (88) Patients with painful TMD frequently report sleep disturbances. (51) The Fonseca Anamnestic Index provides a list of screening questions to identify and quantify the severity of TMD. (63-67)

Clinicians should be particularly vigilant for cardiac origins of jaw pain, particularly in higher-risk populations. A TMD consensus panel identified the following functional assessments as the most useful for identifying TMD: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD), and the Neck Disability Index (NDI). (48)

Clinical evaluation for TMD should include visual and palpatory assessment of the opening pattern (mouth opening test), while observing lateral deviation and “jerky” movements. (48) Vertical interincisal opening of less than 40mm is considered restricted. (11) Congenitally missing tooth is the most common dental abnormality and is a risk factor for TMD (117) Clinicians should assess for audible or palpable joint clicking or crepitus of the TMJ upon opening and closing. (48) TMD patients tend to exhibit a hypolordotic or kyphotic neck posture. (50) Cervical spine muscle weakness and hypomobility are common in TMD patients. (70,75) TMD patients often exhibit cervical spine motion limitations, particularly in the upper segments. (54,55)

Palpation may reveal tenderness in the: suboccipitals, temporalis, masseter, anterior and posterior digastrics, pterygoids, SCM and trapezius. Intersegmental mobility of the cervicocranial junction, cervical spine, and upper thoracic spine should be assessed. Hyoid mobility is assessed by moving the hyoid side to side in a supine patient. Limited or asymmetric hyoid mobility suggests digastric tension. Orthopedic evaluation should also include the centric relation provocation test, which tests the disc-condyle complex in the most stable position. Since the disc is not innervated, compression of the mandible into the temporal fossa should not elicit symptoms in healthy joints. Reproduction of pain means the condyle is contacting the fossa, suggesting a structural pathology (i.e. disc dislocation, osteoarthritis, or capsulitis).

Diagnostics & Differential

In many cases, TMD cannot be assessed by clinical evaluation alone. Panoramic x-rays are of limited help in identifying articular causes of TMD. CT is the imaging of choice (over 4 times better than plain films) for identifying TMJ osteoarthritis. Advanced imaging signs of TMD include disc displacement/ deformation, joint effusion, osteoarthritis, and increased thickness of roof of glenoid fossa. (38,58,61) Current studies with CT also indicated a likely relationship between mandibular asymmetries and TMD. (91) The reliability of MRI is excellent for detecting disc displacements and effusion. (12) Diagnostic ultrasound is a non-invasive modality that is less expensive and does not demand special facilities while producing dynamic images with good identification of disc displacement. (33,105) Patients with TMD do not demonstrate significant EMG variations as compared to healthy controls. (47)

The differential diagnosis of TMD would include disc displacement, degeneration, fracture, infection (i.e., parotid gland, tooth), dental pathology, neoplasm, trigeminal neuralgia, and cardiogenic referral.

Management

Non-surgical intervention for TMD has been shown to be as effective as any surgical intervention. (13,108,122) Management should be conservative and simple, focusing on three main points: manual therapies, exercise, and avoidance of aggravating activities. (52) Muscle energy technique and occlusal splint therapy as a combined therapy were shown to significantly reduce pain and improve mouth opening. (92)

Manual therapy has varied support as an effective treatment for TMD. (30,49,52,68,83,121,123) Upper cervical manipulation appeared to have the most impact in decreasing symptoms of TMD with manual therapy. (107,119) Manual therapies may be necessary to address lesions in the masticatory system, neck and upper torso. Intraoral myofascial therapy has been shown to reduce pain and improve jaw opening. (29) Post-isometric relaxation (PIR), STM, or myofascial release should be directed at the: lateral pterygoid, temporalis, and masseter. (14,15) Other muscles that may need consideration include the: suboccipitals, anterior and posterior digastrics, medial pterygoid, SCM, and trapezius. (72)

TMJ non-thrust mobilization is often indicated (10) and may be performed by grasping the jaw with the clinician’s thumbs on the molars, applying distraction, and moving the jaw in a figure-eight clockwise or counterclockwise fashion for 20 repetitions. HVLA manipulation of the jaw is controversial and shows only limited short-term benefit. (32) Manipulation of the cervicocranial, cervical, and thoracic spine may be helpful. (16,44) Upper cervical manipulation has demonstrated benefit in chronic TMD cases. (36) Chiropractic cervical spine manipulation has been shown to increase maximal bite force. (31) Before conducting cervical manipulation, providers should screen for potential contraindications.

Exercises to improve posture and TMJ function have been shown to be beneficial (10,17,18,52,83,97,112,114,118,121). Stretching exercises should address tightness in the masseter, SCM, levator and suboccipitals. The patient should also perform chin retractions, deep neck flexion and chin depression. Additional postural corrections may be necessary, particularly for deep neck flexor weakness. (75,124). The Rocabado 6×6 exercise protocol is a popular program to restore function between the jaw, neck, and shoulders. (22) In contrast to popular opinion, some experts suggest that management of malocclusion is not essential in the treatment of TMD. (19)

Initially, passive modalities including, heat, ice, ultrasound, or iontophoresis may be helpful. (20,28,35,40) One systematic review concluded that laser therapy is helpful for TMD. (61) Extracorporeal Shockwave Therapy (ESWT) has demonstrated benefit for TMD patients. (53) Acupuncture has been shown to reduce pain in TMD patients. (55,76) Laser acupuncture and low-level diode laser therapy were shown to have similar efficacy in the treatment of the myofascial pain of TMD. (98,103) Localized vibration therapy may provide pain relief. (71) Microcurrent Electrical Nerve Stimulation [MENS] therapy is an effective non-invasive treatment that can be used to reduce pain in patients with myofascial pain of the masticatory muscle. (94,96) TENS and high voltage currents are also valid options for the control of pain intensity in patients suffering from temporomandibular disorder. although the quality of evidence supporting this study was considered low. (116)

Patients should avoid aggravating activities like chewing gum or eating “rubbery” foods. Patients should limit unnecessary talking. (18,19) Home education should include instruction on how to maintain a relaxed jaw position. (79) Glucosamine and chondroitin sulfate have shown success in managing TMD. (34) Supplementation with bromelain or MSM may also be beneficial. A gluten-free diet was shown to be effective in reducing chronic myofascial pain in masticatory muscles. (87) A custom-fitted mouthguard (occlusal orthotic) may help minimize grinding or clenching and promote relaxation of masticatory muscles. (20) Patients with nighttime symptoms should avoid stressful activity before bedtime and be aware of their sleep position. NSAIDs may provide benefit. Patients with TMD typically have higher anxiety levels and lower quality of life scores. (41) Long-term strategies should address any biopsychosocial factors. There is an increased probability of TMD among patients with a history of certain mental and behavioral disorders, and a stronger association with TMD requiring surgery, specifically repeated surgery. (109) The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise. (111) In some cases, stress management techniques, like biofeedback, can assist patients in learning how to relax the jaw muscles. Stem cell therapy may provide benefits for damaged TMJ components. (78)

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