51 - Temporomandibular Joint Pain

51
Temporomandibular
Joint Pain
DANIEL M. LASKIN
KEY POINTS
Temporomandibular joint (TMJ) pain must be distinguished
from the pain that more commonly arises from the muscles
of mastication (myofascial pain), which can produce similar
signs and symptoms.
are known, only three types are considered to generally
produce pain: the various arthritides, derangements of the
intra-articular disk, and certain neoplasms.
TMJ pain also must be distinguished from pain coming from
the ear or parotid gland.
ARTHRITIS OF THE
TEMPOROMANDIBULAR JOINT
TMJ pain and masticatory muscle pain generally are
accompanied by limitation of mouth opening, but not pain
arising from the ear or parotid gland.
Arthritis is the most common painful condition affecting
the TMJ. Although osteoarthritis and rheumatoid arthritis
are encountered most frequently, cases of infectious arthritis, metabolic arthritis, and presentation as part of the spondyloarthropathies are also seen in practice. Traumatic
arthritis is another relatively common occurrence.
Most major systemic arthropathies may also involve the TMJ
and thereby give rise to pain and limited jaw movement.
Displacement of the intra-articular disk in the TMJ produces
pain that is accompanied by a clicking or popping sound or
sudden onset of jaw locking.
Pain in the temporomandibular joint (TMJ) region, a commonly encountered symptom, affects more than 10 million
Americans. Because of its diverse causes, however, considerable difficulty is often involved in proper diagnosis and
treatment. Owing to the proximity of the ear and parotid
gland and the similar nature of pain in these areas, pathologic conditions involving these structures are often confused with conditions arising in the TMJ. Pain occurring
in the adjacent muscles of mastication, also a frequently
encountered situation, not only is similar to TMJ pain in
character and location, but also is associated with jaw dysfunction, a common finding with painful conditions directly
involving the TMJ. For these reasons, knowledge of the
various painful conditions occurring in the TMJ region is
essential in establishing a correct diagnosis.
Because patients with primary TMJ disease often have
secondary myofascial pain in the muscles of mastication,
and because patients with primary myofascial pain problems
in the masticatory muscles can develop secondary TMJ
disease, the generally accepted term used to describe this
overlapping group of conditions is temporomandibular disorders. These conditions are subdivided for purposes of diagnosis and treatment into conditions that primarily involve
the TMJ (TMJ problems) and conditions that primarily
involve the muscles of mastication (myofascial pain and
dysfunction [MPD], masticatory myalgia). From a diagnostic
standpoint, it is important to consider the numerous conditions that mimic the temporomandibular disorders or MPD
by producing similar signs and symptoms (Tables 51-1 and
51-2).
Table 51-3 lists the various pathologic entities that commonly involve the TMJ. Although a variety of conditions
Osteoarthritis
Osteoarthritis is the most common type of arthritis involving the TMJ and the most frequent cause of pain in that
region. Clinical symptoms of the disease have been reported
in 16% of the general population,1 but radiographic features
have been found in 44% of asymptomatic individuals.2
Although the TMJ is not a weight-bearing joint in the same
sense as the joints of the long bones, the stresses associated
with such parafunctional habits as clenching and grinding
of the teeth are sufficient to contribute to similar degenerative changes in some patients.3 Acute and chronic trauma
and derangements of the intra-articular disk also are
common causes of secondary degenerative arthritis.
Clinical Findings
Primary osteoarthritis, which usually is seen in older individuals, is insidious in its onset; it generally produces only
mild discomfort, and individuals rarely complain about
the condition. Secondary osetoarthritis usually occurs in
younger patients (20 to 40 years old) and tends to be painful.
In contrast to primary degenerative joint disease and rheumatoid arthritis, it often is limited to only one TMJ,
although it may become bilateral in the late stages, and
involvement of other joints is uncommon. The condition
is characterized by TMJ pain that is increased by function,
joint tenderness, limitation of mouth opening, and occasional clicking and popping sounds. In the late stages, crepitation may be noted in the joint.
Imaging Findings
The earliest radiologic feature of osetoarthritis of the TMJ,
whether primary or secondary, is subchondral sclerosis
in the mandibular condyle. If the condition progresses,
721
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PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Table 51-1 Differential Diagnosis of Nonarticular Conditions Mimicking Temporomandibular Joint Pain or
Myofascial Pain in the Masticatory Muscles
Jaw
Limitation
Muscle
Tenderness
Pulpitis
No
No
Pericoronitis
Yes
Possible
Otitis media
No
No
Parotitis
Yes
No
Sinusitis
No
No
Trigeminal neuralgia
No
No
Atypical (vascular)
neuralgia
Temporal arteritis
No
No
No
No
Trotter’s syndrome
Yes
No
Eagle’s syndrome
No
No
Disorder
Diagnostic Features
Mild to severe ache or throbbing; intermittent or constant;
aggravated by thermal change; eliminated by dental anesthesia;
positive radiographic findings
Persistent mild to severe ache; difficulty swallowing; possible fever;
local inflammation; relieved with dental anesthesia
Moderate to severe earache; constant pain; fever; usually history of
upper respiratory infection; no temporomandibular joint
tenderness
Constant aching pain, worse when eating; pressure feeling; absent
salivary flow; ear lobe elevated; suppuration from duct
Constant aching or throbbing; worse with change of head position;
nasal discharge; often maxillary molar pain not relieved by dental
anesthesia
Sharp stabbing pain of short duration; trigger zone; pain follows
nerve pathway; older age group; often relieved by dental
anesthesia
Diffuse throbbing or burning pain of long duration; often associated
autonomic symptoms; no relief with dental anesthesia
Constant throbbing preauricular pain; artery prominent and tender;
low-grade fever; may have visual problems; elevated erythrocyte
sedimentation rate
Aching pain in ear, side of face, and lower jaw; deafness; nasal
obstruction; cervical lymphadenopathy
Mild to sharp stabbing pain in ear, throat, and retromandible;
provoked by swallowing, turning head, carotid compression;
usually post tonsillectomy; styloid process >2.5 cm
Modified from Laskin DM, Block S: Diagnosis and treatment of myofascial pain dysfunction (MPD) syndrome, J Prosthet Dent 56:75–84, 1986.
condylar flattening and marginal lipping may be noted. In
the later stages, erosion of the cortical plate, osteophyte
formation, or both may occur. Breakdown of the subcortical
bone occasionally may result in the formation of bone cysts.
Although changes in the articular fossa generally are not as
severe as changes in the condyle, cortical erosion sometimes
can be seen. Narrowing of the joint space also occurs in the
late stages; this is indicative of concomitant degenerative
changes in the intra-articular disk. Although changes in the
TMJ usually can be seen on plain radiographs, sagittal and
coronal computed tomography (CT) scans are the preferred
modality for imaging the bony structures.
Table 51-2 Differential Diagnosis of Nonarticular Conditions Producing Limitation of Mandibular Movement
Jaw
Limitation
Muscle
Tenderness
Odontogenic infection
Yes
Yes
Nonodontogenic infection
Yes
Yes
Myositis
Yes
Yes
Myositis ossificans
No
No
Possible
Possible
Scleroderma
No
No
Hysteria
No
No
Tetanus
Yes
No
Extrapyramidal reaction
No
No
Depressed zygomatic arch
Possible
No
Osteochondroma coronoid
No
No
Disorder
Neoplasia
Diagnostic Features
Fever; swelling; positive radiographic findings; tooth tender to
percussion; pain relieved and movement improved with
dental anesthesia
Fever; swelling; negative dental findings on radiograph; dental
anesthesia may not relieve pain or improve jaw movement
Sudden onset; jaw movement associated with pain; areas of
muscle tenderness; usually no fever
Palpable nodules seen as radiopaque areas on radiograph;
involvement of nonmasticatory muscles
Palpable mass; regional nodes may be enlarged; may have
paresthesia; radiograph may show bone involvement
Skin hard and atrophic; mask-like facies; paresthesias; arthritic
joint pain; widening of periodontal ligament
Sudden onset after psychological trauma; no physical findings;
jaw opens easily under general anesthesia
Recent wound; stiffness of neck; difficulty swallowing; spasm of
facial muscles; headache
Patient on antipsychotic drug or phenothiazine tranquilizer;
hypertonic movement; lip smacking; spontaneous chewing
motions
History of trauma; facial depression; positive radiographic
findings
Gradual limitation; jaw may deviate to unaffected side; possible
clicking sound on jaw movement; positive radiograph findings
Modified from Laskin DM, Block S: Diagnosis and treatment of myofascial pain dysfunction (MPD) syndrome, J Prosthet Dent 56:75–84, 1986.
CHAPTER 51 Diagnosis
The diagnosis of osteoarthritis is based on the patient’s
history and clinical and radiographic findings. A history
of trauma or parafunctional oral habits is often reported.
Involvement is generally unilateral, and no significant
changes are observed in any of the other joints. The pain
tends to be well localized, and the TMJ is often tender to
palpation.
Treatment
Treatment of degenerative arthritis of the TMJ is usually
medical, as in other joints of the body. It involves the
use of nonsteroidal anti-inflammatory drugs, application of
heat, eating a soft diet, limitation of jaw function, and use
of a bite appliance to control parafunction if the patient has
a chronic habit of clenching or grinding the teeth. Arthrocentesis has also been shown to be helpful.4,5 Physical
therapy with thermal agents, ultrasound, and iontophoresis
also can be beneficial, and isotonic and isometric exercises
are used to improve joint stability after acute symptoms
have subsided. The use of intra-articular steroid injections
is controversial; they should be used only in patients
with acute symptoms that do not respond to other forms
of medical management. Because of the potentially damaging effects of long-acting steroids,4,6 they should be limited
to no more than three or four single injections given
at 3-month intervals. Intra-articular injection of highmolecular-weight sodium hyaluronate given twice, 2 weeks
apart, has been shown to have essentially the same therapeutic effect as a steroid injection, without the potential
adverse effects.5,7
When the acute symptoms have been controlled, therapy
is directed toward control of factors possibly contributing
to the degenerative process. Unfavorable loading of the
joint is eliminated by replacement of missing teeth to establish a good, functional occlusion; by correction of any severe
dental malrelationships through orthodontics or orthognathic surgery; and by continued use of a bite appliance
at night to control teeth-clenching or teeth-grinding
habits.6,8
In patients in whom medical management for 3 to 6
months fails to relieve the symptoms, surgical management
may be indicated. Surgery involves removal of only the
minimal amount of bone necessary to produce a smooth
articular surface. Unnecessary removal of the entire cortical
plate, as occurs with the so-called condylar shave procedure
or high condylotomy, can lead to continuation of the resorptive process in some instances, and should be avoided if
possible.
Rheumatoid Arthritis
More than 50% of patients with rheumatoid arthritis have
involvement of the TMJ.9 Although the TMJ may be
affected early in the course of the disease, other joints in
the body usually are involved first. The general female-tomale ratio is 3 : 1. TMJ involvement may also characterize
juvenile inflammatory arthritis. In children, destruction of
the mandibular condyle by the disease process results in
growth retardation and facial deformity characterized by a
| Temporomandibular Joint Pain
723
severely retruded chin. Fibrous or bony ankylosis is a possible sequel at all ages.
Clinical Findings
Patients with rheumatoid arthritis of the TMJ have bilateral
pain, tenderness, swelling in the preauricular region, and
limitation of mandibular movement. These symptoms are
characterized by periods of exacerbation and remission.
Joint stiffness and pain are usually worse in the morning and
decrease during the day. The limitation in mandibular
movement worsens as the disease progresses; the patient
also may develop an anterior open bite.
Imaging Findings
Although radiographic changes may not be noted in the
early stages of the disease, about 50% to 80% of patients
show bilateral evidence of demineralization, condylar flattening, and bone erosion as the disease progresses, so the
articular surface appears irregular and ragged. Erosion of the
glenoid fossa also is seen sometimes. Narrowing of the joint
space is caused by destruction of the intra-articular disk.
With continued destruction of the condyle, loss of ramus
height can lead to contact of only the posterior teeth and
an anterior open bite.
Diagnosis
Rheumatoid arthritis is diagnosed on the basis of the
history, clinical and radiographic findings, and confirmatory
laboratory tests. Distinguishing features for rheumatoid
arthritis and degenerative arthritis of the TMJ are shown in
Table 51-3.
Treatment
Treatment of rheumatoid arthritis of the TMJ is similar to
that provided for other joints.7,10 Anti-inflammatory drugs
are used during the acute phases, and mild jaw exercises are
used to prevent excessive loss of motion when acute symptoms subside. In severe cases, disease-modifying drugs, such
as methotrexate, and biologic agents, including etanercept,
infliximab, adalimumab, certolizumab, golimumab, abatacept, tocilizumab, and rituximab, may be used pending systemic presentation. Orthognathic surgery may be necessary
in patients with an anterior open bite after the disease goes
into remission, or in patients in whom ankylosis develops
after that condition is corrected.
Spondyloarthropathies
In addition to the adult and juvenile forms of rheumatoid
arthritis, psoriatic arthritis, ankylosing spondylitis, and reactive arthritis also can involve the TMJ.8-13
Psoriatic Arthritis
Psoriatic arthritis occurs in approximately one-third of
patients who have cutaneous psoriasis. It can have a sudden
onset, can be episodic in nature, and may show spontaneous
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PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Table 51-3 Differential Diagnosis of Temporomandibular Joint (TMJ) Diseases
Disorder
Jaw
Limitation
Muscle
Tenderness
Agenesis
No
Yes
Condylar hypoplasia
No
No
Condylar hyperplasia
No
No
Possible
Yes
Infectious arthritis
Yes
No
Rheumatoid arthritis
Yes
Yes
Spondyloarthropathies
Psoriatic arthritis
Yes
Yes
Ankylosing spondylitis
Yes
Yes
Metabolic arthritis
Gout
Yes
Yes
Pseudogout
Yes
Yes
Traumatic arthritis
Yes
Yes
Degenerative arthritis
Yes
Yes
Ankylosis
No
Yes
Internal disk degeneration
Yes
Yes
Neoplasia
Diagnostic Features
Congenital; usually unilateral; mandible deviates to affected side;
unaffected side long and flat; severe malocclusion; often ear
abnormalities; radiograph shows condylar deficiency
Congenital or acquired; affected side has short mandibular body and
ramus, fullness of face, deviation of chin; body of mandible
elongated and face flat on unaffected side; malocclusion;
radiograph shows condylar deformity, antegonial notching
Facial asymmetry with deviation of chin to unaffected side;
cross-bite malocclusion; prognathic appearance; lower border of
mandible often convex on affected side; radiograph shows
symmetric enlargement of condyle
Mandible may deviate to affected side; radiographs show enlarged,
irregularly shaped condyle or bone destruction, depending on
type of tumor; unilateral condition
Signs of infection; may be part of systemic disease; radiograph may
be normal early, later can show bone destruction; fluctuance may
be present; pus may be obtained on aspiration; usually unilateral
Signs of inflammation; findings in other joints (hands, wrists, feet,
elbows, ankles); positive laboratory test results; retarded
mandibular growth in children; anterior open bite; radiograph
shows bone destruction; usually bilateral
Presence of cutaneous psoriasis; nail dystrophy; involvement of
distal interphalangeal joints; radiograph shows condylar erosion;
negative for rheumatoid factor
Frequent involvement of the spine and sacroiliac joint; extra-articular
manifestations of spondylitis include iritis, anterior uveitis, aortic
insufficiency, and conduction defects; erosive condylar changes;
TMJ ankylosis may occur
Usually sudden onset; often monoarticular; commonly involves great
toe, ankle, and wrist; joint swollen, red, and tender; increased
serum uric acid; late radiographic changes
Generally unilateral; TMJ may be only joint involved; joint frequently
swollen; presence of intra-articular calcification; may be a history
of trauma
History of trauma; radiograph normal except for possible widening
of joint space; local tenderness; usually unilateral
Unilateral joint tenderness; often crepitus; TMJ may be only joint
involved; radiograph may be normal or show condylar flattening,
lipping, spurring, or erosion
Usually unilateral, but can be bilateral; may be history of trauma;
young patient may show retarded mandibular growth;
radiographs show loss of normal joint architecture
Pain exacerbated by function; clicking on opening or opening
limited to <25 mm with no click; positive magnetic resonance
imaging findings; may be history of trauma; usually unilateral
Modified from Laskin DM, Block S: Diagnosis and treatment of myofascial pain dysfunction (MPD) syndrome, J Prosthet Dent 56:75–84, 1986.
remission.9,12 Often only one TMJ is involved. Symptoms
include TMJ pain and tenderness, restricted jaw movement,
and crepitation, mimicking the symptoms of rheumatoid
arthritis.9,12 Radiographic changes are nonspecific and
cannot be distinguished easily from those of other types of
arthritis, particularly rheumatoid arthritis and ankylosing
spondylitis.13,14 They usually involve erosive changes in the
condyle and glenoid fossa associated with extreme narrowing of the joint space.11,15,16 In severe cases, ankylosis may
develop, reflected occasionally in new bone formation at
earlier stages.12,17
The diagnosis usually is based on the triad of psoriasis,
radiographic evidence of erosive arthritis, and a negative
serologic test for rheumatoid factor. Even in the presence of
a rash, however, the diagnosis cannot be absolutely confirmed. The differential diagnosis always should include
rheumatoid arthritis, reactive arthritis, ankylosing spondylitis, and gout.
Treatment of psoriatic arthritis of the TMJ is similar to
that of rheumatoid arthritis, and is driven essentially by
the imperative to treat the systemic inflammatory disease
process.13,18-21 Surgery is necessary if ankylosis occurs.
Ankylosing Spondylitis
About one-third of patients with ankylosing spondylitis
develop TMJ involvement several years after onset of the
disease. Pain and limitation of jaw movement are the most
common symptoms, and ankylosis can develop in advanced
cases.8,11,14,22 On radiographic examination, about 30% of
patients show erosive changes in the condyle and fossa and
narrowing of the joint space.15,23 In long-standing cases, a
CHAPTER 51 more florid osteophytic response is sometimes seen during
quiescent periods. The severity of the changes seems to be
related to the severity of the disease. Treatment of ankylosing spondylitis of the TMJ is generally medical and is part
of the total management of the patient. Physical therapy is
used to improve jaw mobility, and bite appliances are used,
when indicated, to reduce parafunctional stress on the joint.
If ankylosis develops, surgery is the treatment of choice.24
| Temporomandibular Joint Pain
725
Chills, fever, sweating, and systemic findings characteristic
of the specific type of infection also are present. Often the
teeth cannot be occluded because of swelling within the
joint. In pyogenic forms of infectious arthritis, fluctuation
may be noted in the joint region. Patients with Lyme
disease show characteristic skin lesions and often positive
serology.18,29
Imaging Findings
Reactive Arthritis
Reactive arthritis of the temporomandibular joint is more
common in males than in females. It is characterized by
recurrent pain, swelling, and limitation of mouth opening.25
Radiographically, condylar erosion may be evident.26 Treatment is similar to that of the other seronegative spondyloarthropathies, consisting of nonsteroidal anti-inflammatory
drugs, intra-articular steroids, and disease-modifying drugs.
If a specific triggering bacterial infection can be identified,
an appropriate antibiotic should be prescribed.
Traumatic Arthritis
Acute trauma to the mandible that does not result in a
fracture can still produce injury to the TMJ. When this
occurs in a child, it is essential to warn the parents about
the possibility of future retardation of mandibular growth
and associated facial deformity resulting from damage to the
articular cartilage, which is an important growth site.16,27
Traumatic arthritis is characterized by TMJ pain and
tenderness and limitation of jaw movement. The resultant
inflammation and occasional hemarthrosis can lead to loss
of tooth contact on the affected side. Frequently, bruises or
lacerations are apparent at the site of the initial injury. No
radiographic changes may be seen, or widening of the joint
space may be produced by intra-articular edema or hemorrhage. In some instances, radiographs may show an intracapsular fracture that was not recognized on clinical
examination.
Treatment of traumatic arthritis consists of the use of
nonsteroidal anti-inflammatory drugs, application of heat, a
soft diet, and initial restriction of jaw movement. When
acute symptoms subside, range-of-motion exercises should
be used to avoid fibrous ankylosis.
Infectious Arthritis
Infectious arthritis rarely involves the TMJ. Although it can
affect the joint as part of such systemic diseases as gonorrhea, syphilis, tuberculosis, and Lyme disease,17,18,28,29 the
most common way is by direct extension of an adjacent
infection of dental, parotid gland, or otic origin.19,30 Occasionally, it also may occur from localization of blood-borne
organisms in the joint after a traumatic injury or by direct
involvement through a penetrating wound.20,30 The most
common pathogens are Staphylococcus aureus, Haemophilus
influenzae, and Streptococcus species.31
Clinical Findings
Infectious arthritis generally results in unilateral pain, tenderness, swelling, and redness in the region of the TMJ.
Radiographic findings are usually normal in early stages of
the disease because of lack of bony involvement, but the
intra-articular accumulation of pus or inflammatory exudate
may cause separation of articulating surfaces, which can be
detected on magnetic resonance imaging (MRI). Later,
depending on the severity and chronicity of the infection,
varying degrees of bony destruction, ranging from damage
to the articular surface of the mandibular condyle to extensive osteomyelitis, may be seen. In the late stages, fibrous or
bony ankylosis may occur. In children, infectious arthritis
can affect growth of the condyle, resulting in facial
asymmetry.
Treatment
Treatment of infectious arthritis includes the use of appropriate antibiotics, proper hydration, control of pain, and
limitation of jaw movement. Arthrocentesis with Ringer’s
solution one to three times weekly until acute symptoms
subside has also been recommended.32 Suppurative infections may require aspiration, incision, and drainage, or
sequestrectomy. When bone loss has been extensive, reconstructive procedures may be necessary. In children in whom
mandibular growth has been affected, a costochondral graft
can be used to correct facial asymmetry and re-establish
growth of the mandible.
Metabolic Arthritis
Metabolic arthritis, which can accompany gout or pseudogout (calcium pyrophosphate dehydrate arthropathy), is
rare in the TMJ.21,33
Gout
Gouty arthritis of the TMJ occurs most frequently in men
older than 40 years and usually is preceded by involvement
of one or more joints of the feet or hands. The attack usually
occurs suddenly, and the joint becomes swollen, painful,
red, and tender. Recovery may occur in a few days, and
remission can last for months to years.
When attacks are infrequent, radiographic changes may
not be noted for a long time. Because so few cases have been
reported, the precise radiographic changes that occur have
not been well documented. Calcified areas in the disk,
destruction of the hard tissues of the joint, condylar exostoses and spurring, and the presence of tophi have been
described.21,33-35 The initial approach to treatment of gout
involving the TMJ is medical. If symptoms are not controlled, however, surgical débridement of the joint and
arthroplasty may be indicated.
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PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
A
Pseudogout
Calcium pyrophosphate dehydrate arthropathy (pseudo­
gout) in the TMJ clinically mimics gout, and the mandibular condyle may show degenerative and erosive changes
radiographically. In the primary form, which usually is seen
in older patients, intra-articular calcification is noted
(chondrocalcinosis), and diffuse calcification occurs in the
intra-articular disk.21-25,36-39 Similar changes are seen in the
secondary form, but it occurs in younger patients and frequently is preceded by a history of trauma. Just as in gout
of the TMJ, the initial treatment of pseudogout is medical,
and surgery is reserved for patients in whom such treatment
is ineffective.
E
B
INTERNAL DERANGEMENTS
Internal derangements are a common cause of pain in the
TMJ. They represent a disturbance in the normal anatomic
relationship between the intra-articular disk and the
condyle, resulting in interference with the smooth movement of the joint.
Clinical Findings
Three stages of internal derangement have been identified:
(1) a painless incoordination phase, in which a momentary
catching sensation is felt during mouth opening; (2) anterior disk displacement with reduction into the normal position during mouth opening, which is characterized by a
clicking or popping sound (Figure 51-1); and (3) anterior
disk displacement without reduction on attempted mouth
A
D
C
Figure 51-2 A-E, Anterior displacement of the intra-articular disk
without reduction on attempted mouth opening. The displaced disk acts
as a barrier and prevents full translation of the condyle. (Modified from
McCarty W: Diagnosis and treatment of internal derangements of the articular disc and mandibular condyle. In Solberg WK, Clark GT, editors: Temporomandibular joint problems: biologic diagnosis and treatment, Chicago,
1980, Quintessence, p 151.)
opening, which is characterized by restriction of jaw movement, or locking (Figure 51-2). Joint pain in patients with
anterior disk displacement, with or without reduction, is
caused by condylar compression of the highly innervated
retrodiskal tissue that occupies the glenoid fossa as the
intra-articular disk assumes a more forward position, and by
the accompanying inflammation.
Etiology
Closing click
F
B
Opening click
E
C
D
Figure 51-1 Anterior displacement of the intra-articular disk with
reduction on opening of the mouth. A clicking or popping sound occurs
as the disk returns to its normal position in relation to the condyle.
During closure, the disk again becomes anteriorly displaced, sometimes
accompanied by a second sound (reciprocal click). (Modified from McCarty
W: Diagnosis and treatment of internal derangements of the articular disc
and mandibular condyle. In Solberg WK, Clark GT, editors: Temporomandibular joint problems: biologic diagnosis and treatment, Chicago, 1980,
Quintessence, p 155.)
The three main causes of internal derangement of the intraarticular disk are trauma, abnormal functional loading of
the joint, and degenerative joint disease.26,40 It has been
suggested that spasm in the lateral pterygoid muscle, a
portion of which attaches to the anterior aspect of the disk,
can lead to a disk derangement, but evidence for this theory
is circumstantial. Although some clinicians believe that
occlusal factors also play a role in causing internal derangements, no conclusive studies have shown such a
relationship.
Acute macrotrauma is probably the most common cause
of internal derangement. Among the incidents that have
been implicated are a blow to the jaw, endotracheal intubation, cervical traction, and iatrogenic stretching of the joint
during dental or oral surgical procedures. Although whiplash injuries frequently have been implicated in the development of internal derangement, a study of 155 patients
with this type of injury showed that only 1 developed clicking in the TMJ immediately after the automobile accident.27,41 At 1 month of follow-up, two additional patients
of the 129 contacted experienced clicking, but at 1 year, no
additional patients of the 104 contacted had developed
clicking. Although internal derangements of the TMJ can
be caused by a whiplash injury, the incidence seems to
be low.
CHAPTER 51 Whether a patient merely develops alterations in the
articular surface leading to a catching or binding sensation,
anterior disk displacement with reduction on mouth opening
(clicking or popping), or anterior disk displacement without
reduction during mouth opening (locking) after trauma to
the TMJ depends on the severity of the injury. Although
associated traumatic arthritis causes pain during function in
each of these instances, the pain is more severe in the last
two conditions because of compression of retrodiskal tissue,
which is now located in the articular zone.
Functional overloading of the TMJ associated with the
habit of chronic teeth clenching is another frequent cause
of internal derangements. Although the TMJ is constructed
for eccentric movements, it is not constructed for the constant isometric loading and unloading that occurs during
this activity. Such parafunction affects the lubrication of the
joint and alters the articular surfaces, introducing friction
between the disk and the condyle that leads to degenerative
changes in the articular surfaces and results in gradual anterior displacement of the disk.26,28,40,42
Degenerative joint disease may precede the development
of an internal derangement, or it may occur after the development of an internal derangement. In the first instance,
changes in the character of the articulating surfaces result
in an inability of the parts to glide smoothly over each
other, gradually leading to forward displacement of the disk,
which normally rotates posteriorly during mouth opening.
In the second instance, the displaced disk results in an
altered relationship between articulating components of the
joint, which leads to degenerative changes in these structures. In patients in whom the condition causing the degenerative joint disease is still active, whether primarily or
secondarily, the condition and the disk derangement must
be treated for the problem to be resolved completely.
Imaging Findings
Depending on the cause of the internal derangement and
its duration, radiographs may or may not show any evidence
of degenerative joint disease. Magnetic resonance imaging
shows anterior disk displacement in the closed mouth position, however, as well as a return to a normal disk relationship during mouth opening in patients with clicking and
popping; in patients with locking, the disk remains in the
anterior position on attempted mouth opening, and movement of the condyle is limited. A small group of patients
with locking show the intra-articular disk in normal position when the teeth are in occlusion, rather than anteriorly
displaced, and no change in disk position occurs when the
patient attempts to open the mouth.29,43 In such cases, adhesion of the disk to the articular eminence prevents translation of the condyle. These patients differ from those with
anteriorly displaced, nonreducing disks in that they do not
have a history of TMJ clicking preceding the sudden onset
of locking.
Treatment
Initial treatment of patients with painful clicking or popping
in the TMJ consists of a nonsteroidal anti-inflammatory
drug; a soft, nonchewy diet; and use of a bite-opening
appliance to reduce compression of retrodiskal tissue
| Temporomandibular Joint Pain
727
Management of internal
derangements of the TMJ
Clicking
Analgesics
Soft diet
Limited jaw function
Bite appliance
Pain
continues
Pain
relieved
Diskoplasty
Continue bite
appliance in
patients with
parafunction
Locking
Arthrocentesis or
arthroscopic lysis
and lavage
Bite appliance in patients
with parafunction
Pain
continues
Diskoplasty or
diskectomy
Pain
relieved
Continue bite
appliance
Periodic
follow-up
Periodic
follow-up
Figure 51-3 Management of internal derangements of the temporomandibular joint (TMJ). Patients with painful clicking or locking are
treated medically initially, whereas patients with locking require surgical
intervention.
(Figure 51-3). A muscle relaxant drug can be added to the
regimen if the patient has associated myofascial pain. When
the pain has stopped, no further treatment is necessary,
although joint noise still may be present. A long-term
follow-up study (1 to 15 years) of 190 patients with a history
of clicking treated by such conservative nonsurgical modalities, which are not directed specifically to the problems of
joint noise or disk displacement, showed that the condition
worsened in only 1%, indicating that it is permissible to
observe individuals with painless clicking as long as they
remain otherwise asymptomatic.30,44 However, in those
patients who have teeth-clenching and -grinding habits, use
of a bite appliance is indicated to control these habits.
In patients with pain and clicking in the TMJ that is
unresponsive to nonsurgical management, the disk should
be repositioned arthroscopically or by open surgery (diskoplasty). Patients with parafunctional habits should continue the use of a bite appliance when sleeping. In patients
with locking (anterior disk displacement without reduction), whether painful or not, treatment is urgent because
if the condition is left untreated for a long time, subsequent
management can be complicated by further degenerative
changes in the disk and condyle that make disk salvage
(diskoplasty) impossible. Initial treatment involves joint
lavage and lysis of adhesions arthroscopically or by arthrocentesis. The latter involves establishment of inlet and
outlet portals in the upper joint space with hypodermic
needles, irrigation with lactated Ringer’s solution to remove
inflammatory tissue breakdown products and cytokines, and
lysis of adhesions by hydraulic distention and manual
manipulation of the joint (Figure 51-4).31,45
The results of arthrocentesis parallel those achieved with
arthroscopic lysis and lavage, and the procedure is less invasive. Although neither of these procedures restores the disk
to its normal position, they do restore disk and joint mobility, and they reduce pain and improve function in most
728
PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
A
tumor, and synovial hemangioma have been reported.
Malignant tumors of the TMJ are even rarer, with infrequent reports of fibrosarcoma, chondrosarcoma, synovial
fibrosarcoma, osteosarcoma, malignant fibrous histiocytoma, malignant schwannoma, leiomyosarcoma, and multiple myeloma. The TMJ also can be invaded by neoplasms
from the cheek, the parotid gland, the external auditory
canal, and the adjacent ramus of the mandible. Metastasis
to the condyle from distant neoplasms in the breast, lung,
prostate, colon, thyroid gland, liver, stomach, and kidney
has been described.
Tumors of the TMJ can cause pain, limitation of jaw
movement, deviation of the mandible to the affected side
on attempted mouth opening, and difficulty in occluding
the teeth. Depending on the nature of the condition, radiographs may show bony deformation, apposition, or resorption. A biopsy is necessary to establish the definitive
diagnosis.
MYOFASCIAL PAIN AND DYSFUNCTION
B
Figure 51-4 Temporomandibular joint arthrocentesis. A, Hypodermic
needles inserted into the upper joint space to allow lavage of the joint.
B, Joint being irrigated with lactated Ringer’s solution.
patients.32,33,46,47 In these patients, retrodiskal tissue within
the joint undergoes fibrosis and acts as a pseudodisk. It is
important that patients who have teeth-grinding or teethclenching habits are prescribed a bite appliance postoperatively to wear while sleeping.
In patients who do not respond favorably to arthroscopy
or arthrocentesis, the displaced disk should be repositioned
by an open operation. If the disk is extremely deformed and
cannot be repositioned, or if a large, nonreparable perforation in the disk or a tear in the retrodiskal tissue is present,
the disk should be removed. Although autogenous auricular
cartilage or dermal grafts, or temporalis muscle flaps, have
been used as a disk replacement, results have been unpredictable.31,45,48 More recent long-term studies have shown
that most patients can tolerate a diskless joint.34,49 Currently, no acceptable alloplastic substitutes for the disk are
available.
NEOPLASMS
Although primary neoplasms involving the TMJ are uncommon, they must be considered in the differential diagnosis
of painful conditions affecting this region.35,36,50,51 Chondroma, osteochondroma, and osteoma are the most frequently encountered benign tumors, but isolated cases of
fibro-osteoma, myxoma, fibrous dysplasia, giant cell reparative granuloma, aneurysmal bone cyst, synovioma, synovial
chondromatosis, chondroblastoma, osteoblastoma, glomus
Myofascial pain and dysfunction (MPD), or masticatory
myalgia, is considered to be a psychophysiologic disease that
primarily involves the muscles of mastication, and not the
TMJ. Women are affected more frequently than men; the
ratio in various reports ranges from 3 : 1 to 5 : 1. Although
the condition can occur in children, the incidence seems to
be greatest in adults 20 to 40 years old. MPD frequently is
confused with painful conditions affecting the TMJ, such as
degenerative arthritis or internal derangements, because
patients with primary MPD can develop these diseases secondarily, and patients with primary joint disease can develop
secondary MPD. Enhanced understanding of the causes and
pathogenesis of this condition makes its diagnosis easier and
its treatment more effective.37,38,52,53
Etiology
Psychological stress has been suggested as an important
contributing factor in the development of MPD (psychophysiologic theory).39,54,55 It is hypothesized that in most
patients, stress-related, centrally induced increases in
muscle activity, frequently combined with the presence of
parafunctional habits such as clenching or grinding of the
teeth, may result in associated muscle fatigue, pain, and
limited mouth opening.40,54 However, similar symptoms
occasionally have been seen to result from muscle overextension, muscle overcontraction, or trauma (Figure 51-5).
A counter-theory (the pain adaptation theory of Lund)56
has been proposed to suggest that pain in the masticatory
muscles leads to a reduction rather than an increase in
muscle activity as a protective mechanism, and this causes
the limitation in mouth opening.; however, this theory
does not explain the origin of the pain. Despite extensive
research, the cause of myofascial pain and dysfunction
remains unknown.
Clinical Findings
Pain of unilateral origin is the most common symptom of
MPD. In contrast to the pain associated with joint disease,
which is well localized, the pain of muscle origin is more
CHAPTER 51 Stress
Muscular
overextension
Muscular
hyperactivity
“Dental irritation”
Muscular
fatigue
Muscular
overcontraction
Myofascial pain-dysfunction
Contracture
Occlusal
disharmony
Internal
derangement
Degenerative
arthritis
Altered chewing pattern
Figure 51-5 Causes of myofascial pain and dysfunction. Although the
diagram shows three pathways, the one involving psychological stress is
most common. The mechanism by which stress leads to myofascial pain
and dysfunction is termed the psychophysiologic theory. (Modified from
Laskin DM: Etiology of the pain-dysfunction syndrome, J Am Dent Assoc
79:147–153, 1969. Copyright © 1969 American Dental Association. Reprinted
by permission of ADA Publishing Co., Inc.)
diffuse. The patient generally is unable to identify accurately the specific site involved; this can serve as an important diagnostic criterion in distinguishing between muscle
and joint disorders.
Depending on the muscle involved, the pain associated
with MPD may be described by the patient in various ways.
The masseter is the muscle most frequently involved, and
the patient usually refers to the pain as a jaw ache. The
temporalis is the next most commonly involved muscle; it
produces pain on the side of the head, which is interpreted
by the patient as a headache. Involvement of the lateral
pterygoid muscle produces earache or a deep pain behind the
eye, whereas medial pterygoid involvement causes discomfort on swallowing and the feeling of a painful, swollen gland
beneath the angle of the mandible. Medial pterygoid invol­
vement also can cause stuffiness or a full feeling in the ear.
The pain associated with MPD is usually constant, but
it is often more severe on arising in the morning or may
worsen gradually as the day progresses. Pain generally is
exacerbated by jaw function, especially during such activities as eating and excessive talking. Myofascial pain tends
to be regional rather than local, and patients with a longstanding problem may complain that pain in the facial
region has spread to the cervical area and later to the shoulders and back.
Tenderness in the muscles of mastication, another
common finding, can be used to confirm the source of the
pain in muscles that are accessible to palpation (masseter,
temporalis, and medial pterygoid). Although muscle tenderness usually is not reported by the patient, this symptom can
be elicited easily by the examiner. The most frequent sites
of tenderness are near the angle of the mandible, in the
belly and the posterosuperior aspect of the masseter, in the
anterior temporal region, and over the temporal crest on
the anterior aspect of the coronoid process. The location of
some of the tender areas suggests that tendons may be a
source of pain and tenderness.
Limitation of mandibular movement is the third cardinal
symptom of MPD. It manifests as an inability to open the
mouth as wide as usual and as a deviation of the mandible
| Temporomandibular Joint Pain
729
to the affected side when mouth opening is attempted.
Lateral excursion to the unaffected side is reduced. The
limitation of mandibular movement usually is correlated
with the amount of pain present.
A clicking or popping sound in the TMJ is another
finding in some patients with MPD. This is not a cardinal
sign, however, because it occurs only in patients with a
chronic teeth-clenching habit, which gradually produces
frictional changes in the joint and subsequent disk displacement.26,40 The presence of joint sounds alone is insufficient
to allow a diagnosis of MPD. Joint sounds must be accompanied by myofascial pain and tenderness in the masticatory
muscles that began before the onset of the joint noise. Such
patients must be distinguished from patients with a primary
internal derangement, in whom muscle splinting produces
myofascial pain and tenderness after the onset of the joint
noise. The history and differences in physical findings are
helpful in making this distinction.
In addition to having the three cardinal symptoms of
pain, muscle tenderness, and limitation of mouth opening,
patients with MPD usually have no clinical or radiographic
evidence of pathologic changes in the TMJ. These negative
characteristics are important in establishing the diagnosis
because they confirm that the primary site of the problem
is not the articular structures.
Diagnosis
Because the cardinal signs and symptoms of MPD are similar
to those produced by such organic problems involving the
TMJ as degenerative joint disease and internal disk derangement and by a variety of nonarticular conditions (see Tables
51-1 and 51-2), diagnosis of this condition can be difficult,
requiring a careful history and a thorough clinical evaluation. Periapical radiographs of the teeth and screening
radiographs (transcranial, transpharyngeal, or panoramic)
of the TMJs can be helpful in eliminating dental problems
or gross joint disease. If screening views of the TMJs show
some abnormality, CT scans are usually advisable for confirmation. MRI also can be useful in determining the position of the disk when an internal derangement of the TMJ
is being considered. Depending on the suspected condition,
other radiographic views of the head and neck and scintigraphy may be needed to establish a final diagnosis.
Certain laboratory tests may be helpful in some instances.
These include a complete blood cell count if an infection
is suspected; serum calcium, phosphorus, and alkaline phosphatase measurements for possible bone disease; serum uric
acid determination for gout; serum creatinine and creatine
kinase levels as indicators of muscle disease; and erythrocyte
sedimentation rate, rheumatoid factor, latex fixation, and
antinuclear antibody tests for suspected rheumatoid arthritis. Electromyography can be used to evaluate muscle function. Psychological evaluation and psychometric testing are
good research tools, but they have little diagnostic value
other than in identifying the presence of associated abnormal behavioral characteristics.
A condition that sometimes is confused with myofascial
pain is fibromyalgia, particularly when MPD involves several
regions in addition to the face. Although a small subset of
patients with MPD eventually may develop fibromyalgia,
these are probably distinct conditions.41,57 Table 51-4 lists
730
PART 6 | DIFFERENTIAL DIAGNOSIS OF REGIONAL AND DIFFUSE MUSCULOSKELETAL PAIN
Table 51-4 Distinguishing Features of Myofascial
Pain and Fibromyalgia
Myofascial Pain
Fibromyalgia
Age distribution
Gender distribution
Distribution of pain
20-40 years
Mainly women
Localized; usually
unilateral
Tender points
Trigger points
Fatigue
Few
Uncommon
Localized muscle
fatigue
Common
20-50 years
Mainly women
Generalized;
bilaterally
symmetric
Multiple
Common
Generalized
fatigue
Common
Sleep disturbance
becomes symptom free, the medications are stopped first,
and wearing the bite appliance is discontinued next. If the
patient has a return of symptoms, and the appliance is worn
only at night, its use can be continued indefinitely.
Patients who do not respond to the use of a bite appliance are entered into phase III treatment for 4 to 6 weeks.
In this phase, physical therapy (heat, massage, ultrasound,
electrogalvanic stimulation)60 or relaxation therapy (electromyographic biofeedback, conditioned relaxation)61 is
added to the regimen. No evidence shows that one form of
treatment is better than another, and either can be used
Phase I Therapy (2-4 weeks)
the distinguishing characteristics of myofascial pain versus
fibromyalgia.
Treatment
Treatment of MPD is divided into four phases.42,58 When a
definitive diagnosis is made, phase I therapy should be
started (Figure 51-6). Phase I therapy initially involves providing the patient with some understanding of the problem.
Because patients often have difficulty accepting a psychophysiologic explanation for their condition, the discussion
should deal with the issue of muscle fatigue as the cause of
the pain and dysfunction, delaying consideration of the role
of stress and psychological factors until the symptoms have
improved, and the patient’s confidence has been gained.
Relating the symptoms to the specific masticatory muscles
from which they arise helps the patient understand the
reason for the type and location of the pain—headache
from the temporalis muscle, jaw ache from the masseter
muscle, discomfort on swallowing and stuffiness in the ear
from the medial pterygoid muscle, and earache and pain
behind the eye from the lateral pterygoid muscle.
In addition to the initial explanation, the patient should
be counseled regarding home therapy; this includes recommendations about avoidance of clenching and grinding of
the teeth, eating a soft diet, use of moist heat and massage
on the masticatory muscles, and limitation of jaw movement. A nonsteroidal anti-inflammatory drug should be
prescribed for the pain. In patients who have problems
sleeping, a small dose of amitriptyline at bedtime is helpful
in improving sleep and reducing parafunction.
About 50% of these patients experience resolution of
their symptoms within 2 to 4 weeks with phase I therapy.
For patients whose symptoms persist, phase II therapy is
initiated. Home therapy and medications are continued,
and a bite appliance is made for the patient. Although
numerous types have been used, the Hawley-type maxillary
appliance is probably most effective because it prevents
contact of the posterior teeth and prevents most forms of
parafunctional activity (Figure 51-7).43,59 The appliance
generally is worn at night, but it can be worn for 5 to 6
hours during the day, if necessary. The appliance should not
be worn continuously, however, because the posterior teeth
may supraerupt in some patients.
With phase II therapy, another 20% to 25% of patients
become symptom free in 2 to 4 weeks. When the patient
Initial explanation of the problem
Home therapy
Medication for pain and sleep
Symptoms
eliminated
Symptoms persist
Phase II Therapy
(2-4 weeks)
Reevaluate diagnosis
Check for compliance
Phase out therapy
Symptoms
eliminated
Continue home therapy
and medications
Prescribe a bite
appliance
Final explanation
of problem
Instructions for
self-management
Follow-up
appointments
Symptoms persist
Phase III Therapy (4-6 weeks)
Symptoms
eliminated
Continue home therapy
and medications
Reevaluate the bite appliance
Initiate physical therapy
or relaxation therapy
Symptoms persist
Phase IV Therapy
Consultation
Pain center
Psychological
counseling
Figure 51-6 Management of myofascial pain and dysfunction. Treatments are divided into four phases. If the symptoms are eliminated in
any of the first three phases, the ongoing therapy is gradually phased
out, and the patient is instructed in continued self-management of the
condition. (Modified from Laskin DM, Block S: Diagnosis and treatment of
myofascial pain dysfunction [MPD] syndrome, J Prosthet Dent 56:75–84,
1986.)
CHAPTER 51 Figure 51-7 Hawley-type maxillary bite appliance. Only the anterior
teeth contact the appliance, and space between the posterior teeth is
evident (arrow).
first. If one is unsuccessful, the other can be tried. Phase III
therapy usually helps another 10% to 15% of patients.
If all of these approaches fail, and no question arises
about the correctness of the diagnosis, psychological counseling is recommended. This counseling involves helping
patients identify possible stresses in their lives and learning
to cope with such situations. If the diagnosis is in doubt, the
patient should be referred first for appropriate dental and
neurologic consultation and re-evaluation. Another alternative is to refer patients with recalcitrant MPD to a TMJ
center or pain clinic because such patients generally require
a multidisciplinary approach for successful treatment.
SUMMARY
Successful management of patients with temporomandibular disorders depends on establishing an accurate diagnosis
and using proper therapy based on an understanding of the
cause of the condition being treated. Of particular importance is separating patients with MPD, who constitute the
major group encountered and who are not surgical candidates, from patients with TMJ disease, who frequently
require surgical treatment. Even in the latter group, many
commonly encountered conditions, such as arthritis and
internal disk derangements, often respond to nonsurgical
therapy, and this type of treatment should be given a fair
trial before more aggressive management is considered.
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Websites
www.nicdr.nih.gov—General information, clinical trials, and sponsored
research in TMJ and related areas.
www.aaoms.org—General information about TMJ surgery.
www.tmj.org—Advocate group that provides general information for
patients.
The references for this chapter can also be found on www.expertconsult.com.