Temporomandibular Disorders (TMD): Overview
What are temporomandibular disorders (TMD)?
Temporomandibular disorders (TMD) are disorders that develop from problems with the fit between the upper and lower teeth, the jaw joint, and the muscles in the face that control chewing and moving the jaw.
What is the temporomandibular joint (TMJ)?
The temporomandibular joint (TMJ) is the jaw joint. It is the hinge joint that connects the lower jaw (mandible) to the temporal bone of the skull, which is immediately in front of the ear on each side of your head. The joints move smoothly up and down and side to side, which allows you to talk, chew, and yawn. Muscles attached to and surrounding the jaw joint control its position and how it moves.
Symptoms and Causes
What causes temporomandibular disorders (TMD)?
TMD can be caused by injury to the jaw, TMJ, or muscles of the head and neck, such as from a heavy blow. Other causes include:
- Grinding or clenching the teeth (puts a lot of pressure on the TMJ)
- Dislocation of the soft cushion or disc between the ball and socket
- Presence of osteoarthritis or rheumatoid arthritis in the TMJ
- Stress, which can cause a person to tighten muscles in the face and jaw or to clench the teeth
What are the symptoms of temporomandibular disorders (TMD)?
People with TMD can feel severe pain and discomfort that can be temporary or last for many years. TMD is most common in those 20 to 40 years of age and is more common in women than in men.
Symptoms of TMD include:
- Pain or tenderness in the face, jaw joint area, neck and shoulders, and in or around the ear when you chew, speak, or open your mouth wide
- Limited ability to open the mouth very wide
- Jaws that get "stuck" or "lock" in the open- or closed-mouth position
- Clicking, popping, or grating sounds in the jaw joint when opening or closing the mouth. Pain may also be present.
- A tired feeling in the face
- Difficulty chewing or a sudden uncomfortable bite – as if the upper and lower teeth are not fitting together properly
- Swelling on the side of the face
Other common symptoms include toothaches, headaches, neck aches, dizziness, and earaches and hearing problems such as tinnitus.
Diagnosis and Tests
How are temporomandibular disorders (TMD) diagnosed?
Because other conditions cause similar symptoms -- including a toothache, sinus problems, arthritis, or gum disease -- a thorough history and clinical exam is taken. Temporomandibular joints are examined for pain or tenderness; clicking, popping, or grating sounds during jaw movement; limited motion or locking of the jaw while opening or closing the mouth; and bite and facial muscle function.
Panoramic X-rays might be taken. These full face X-rays show the entire jaws, TMJ, and teeth to make sure other problems aren't causing the symptoms. Sometimes other imaging tests are needed. Magnetic resonance imaging (MRI) views the soft tissue, such as the TMJ disc, to see if it is in the proper position as the jaw moves. A computed tomography (CT) scan helps view the bony detail of the joint.
You may be seen by a maxillofacial surgeon for further care and treatment. This doctor specializes in surgical procedures in and about the entire face, mouth, and jaw area.
Management and Treatment
What treatments are available for temporomandibular disorders (TMD)?
Treatments range from simple self-care practices and conservative treatments to injections and open surgery. Most experts agree that treatment should begin with conservative, nonsurgical therapies, with surgery left as the last resort. Many of the treatments listed below often work best when used in combination.
Basic treatments for TMD
- Apply moist heat or cold packs: Apply an ice pack to the side of your face and temple area for about 10 minutes. Do a few simple stretching exercises for your jaw (as instructed by your dentist or physical therapist). After exercising, apply a warm towel or washcloth to the side of your face for about 5 minutes. Do this a few times each day.
- Eat soft foods: Eat soft foods such as yogurt, mashed potatoes, cottage cheese, soup, scrambled eggs, fish, cooked fruits and vegetables, beans, and grains. In addition, cut foods into small pieces. Avoid hard and crunchy foods (like hard rolls, pretzels, raw carrots), thick and large foods that need your mouth to open wide to fit the foods, and chewy foods (like caramels and taffy). Do NOT chew gum.
- Take medications: To relieve muscle pain and swelling, try over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil®, Motrin®), or naproxen (Aleve®).Your dentist can prescribe higher doses of these or other NSAIDs, or other drugs for pain such as narcotic analgesics. Muscle relaxants, especially for people who grind or clench their teeth, can help relax tight jaw muscles. Anti-anxiety drugs can help relieve stress, which is sometimes thought to worsen TMD. A low dose of antidepressants can also help reduce or control pain. Muscle relaxants, anti-anxiety drugs, and antidepressants are available by prescription only.
- Wear a splint or night guard: Splints and night guards are plastic mouthpieces that fit over the upper or lower teeth. They prevent the upper and lower teeth from coming together, which reduces the effects of clenching or grinding the teeth. They also correct the bite by putting the teeth in contact with the splint in their most correct and least traumatic position. The main difference between splints and night guards is that night guards are only worn at night and splints are worn full time (24 hours a day for 7 days). Your dentist will discuss the type of mouth guard appliance you may need.
- Undergo corrective dental treatments: These treatments include replacing missing teeth; or using crowns, bridges, or braces to balance the biting surfaces of your teeth or to correct a bite problem.
- Avoid extreme jaw movements:
- Keep yawning and chewing to a minimum and avoid extreme jaw movements such as yelling or singing.
- Don't rest your chin on your hand or hold the telephone between your shoulder and ear. Practice good posture to reduce neck and facial pain.
- Keep your teeth slightly apart as often as you can to relieve pressure on the jaw. To control clenching or grinding during the day, place your tongue on the palate behind the upper front teeth.
- Learn relaxation techniques to help control muscle tension in the jaw. Ask your dentist about the need for physical therapy or massage. Consider stress reduction therapy, including biofeedback.
More controversial treatments for TMD
When conservative treatments are unsuccessful, your dentist may suggest one or more of the following:
- Transcutaneous electrical nerve stimulation (TENS): This therapy uses low-level electrical currents to reduce pain by relaxing the jaw joint and facial muscles. This treatment can be done at the dentist's office or at home.
- Ultrasound: This is a deep heat treatment that is applied to the temporomandibular joint (TMJ) to relieve soreness or improve joint movement.
- Trigger-point injections: Pain medication or anesthesia is injected into tender muscles of the face (called "trigger points") to relieve pain.
- Radio wave therapy: Radio waves create a low-level electrical stimulation to the joint, which increases blood flow. This provides pain relief in the joint.
Surgery for TMD
Surgery should only be considered after all other treatment options have been tried and severe pain remains. Because surgery cannot be reversed, get a second or even third opinion from other dentists.
There are three types of surgery for TMD: arthrocentesis, arthroscopy, and open-joint surgery. The type of surgery needed depends on the TMD problem.
- Arthrocentesis: This minor procedure is performed in the office under general anesthesia. It can be used when the jaw suddenly locks in the closed position (the jaw cannot be completely opened) or to reduce inflammation in the TMJ. Needles filled with sterile fluids are inserted into the affected joint and the joint is washed out. Occasionally, a surgical instrument is needed to remove scar tissue or to dislodge a disc that has moved out of place. (A disc is a different type of tissue that cushions the area where the jaw bones meet the skull.)
- Arthroscopy: This procedure is performed under general anesthesia. The surgeon makes a small incision in front of the ear and inserts a small, thin instrument that contains a lens and light. This instrument is hooked up to a video screen, which allows the surgeon to examine the TMJ and surrounding area. Depending on the cause of the TMD, the surgeon may remove inflamed tissue or realign the disc or another area of the TMJ.
Because arthroscopic surgery is performed through tiny incisions, there is less scarring, a shorter recovery time, less discomfort, and fewer complications compared with open joint surgery.
Depending on the cause of the TMD, arthroscopy may not be possible, and open-joint surgery needs to be considered.
- Open-joint surgery: Patients undergoing open-joint surgery are also given general anesthesia. Unlike arthroscopy, open surgery is the traditional type of surgery where a long incision is made for the surgeon to insert instruments. Open-joint surgeries may be the approach taken if:
- The bony structures that make up the jaw joint are wearing away.
- There are tumors in or around TMJ.
- There is severe scarring or bone chips in the joint.
Compared with arthroscopy, open-joint surgery results in a longer healing time plus has a greater chance of tissue scarring and nerve injury.