Updated: 8/8/2019

Temporomandibular Disorders

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Questions
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Evidence
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Topic
Snapshot
  • A 31-year-old woman presents to her primary care physican for facial pain. Her pain is dull-like and worsens with mastication or fingernail biting. The pain begins at the jaw and radiates to the ear. Physical examination is notable for tenderness to palpation of the temporomandibular joint, along with a "knocking" sound when the jaw is opened.
Introduction
  • Overview
    • a group of conditions that lead to abnormalities of the muscular and/or articular parts of the temporomandibular joint
  • Epidemiology
    • demographics
      • more common in women
      • greatest risk between 18-44 years of age
    • risk factors
      • rheumatoid arthritis
      • trauma
      • parafunctional chewing habits
        • fingernail biting
        • jaw clenching/bruxism
        • wind instrument playing
  • Pathophysiology
    • mechanism of injury
      • joint trauma
      • poor head and cervical posture
  • Associated conditions
    • other chronic pain disorders
      • migraine
      • fibromyalgias
      • myofascial pain syndrome
  • Prognosis
    • most patients are responsive to treatment and a small percentage of patients develop chronic temporomandibular joint pain
Presentation
  • Symptoms 
    • facial pain
      • unilateral and typically dull-like
      • worsens with jaw motion
      • pain can radiate to the
        • ear
        • temporal region
        • mandible
        • posterior neck
    • headache 
      • ear or preauricular pain
        • radiates to the jaw, temple, or neck
    • neck pain
  • Physical exam
    • facial or jaw tenderness
    • limited mouth opening
    • temporomandibular joint (TMJ) noises with use
Imaging
  • Radiography
    • indications
      • when there is suspicion for 
        • articular disc derangement
        • arthropathy
        • malignancy
    • comments
      • CT and/or MRI is used if radiography is abnormal or if there is severe pain on exam, cranial nerve involvement, or previous surgery in the TMJ
Differential
  • Trigeminal neuralgia
    • differentiating factors
      • pain is described as paroxsymal and severe stabbing pain
Treatment
  • Conservative and lifestyle
    • avoiding triggers
      • indication
        • initial management
      • modalities
        • patients are counseled to adjust 
          • head posture
          • sleeping position
          • parafunctiona oral behaviors (e.g., pen chewing)
  • Medical and pharmacologic
    • nonsteroidal antiinflammatory drugs
      • indication
        • initially pharmacologic therapy for pain management
    • muscle relaxants
      • indication
        • pain upon palpation of the mastication muscles
Complications
  • Headache
  • Jaw deformity and dysfunction

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Questions (2)

(M2.ET.17.4753) A 33-year-old woman presents to her primary care physician complaining of right jaw pain for the last 3 weeks. She first noticed it while eating a steak dinner but generally feels that it is worse in the morning. She describes the pain as deep and dull, with occasional radiation to the ear and back of her neck. She denies any incidents of jaw locking. The patient also states that her husband has noticed her grinding her teeth in her sleep in the last several months. She has a past medical history of depression, for which she takes fluoxetine, and carpal tunnel syndrome, for which she uses a wrist brace. The patient works as a secretary. Her father passed away from coronary artery disease at the age of 54, and her mother has rheumatoid arthritis. At this visit, her temperature is 98.5°F (36.9°C), blood pressure is 135/81 mmHg, pulse is 70/min, and respirations are 14/min. On exam, there is no overlying skin change on the face, but there is mild tenderness to palpation at the angle of the mandible on the right. Opening and closing of the jaw results in a slight clicking sound. The remainder of the exam is unremarkable. Which of the following is the next best step in management?

QID: 108860
1

Nighttime bite guard

65%

(51/79)

2

Plain radiograph of the jaw

30%

(24/79)

3

MRI of the brain

4%

(3/79)

4

Surgical intervention

1%

(1/79)

5

Electrocardiogram

0%

(0/79)

M 7 D

Select Answer to see Preferred Response

(M2.ET.13.1) A 24-year-old woman presents to the emergency department with a severe headache. She states it is 10/10 in intensity and states that it is associated with chewing. She describes it as a dull pain over the sides of her head. The patient is otherwise healthy and is not currently taking any medications. Her temperature is 97.0°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for pain and tenderness over the mandibular and temporal region that is worsened when the patient opens and closes their mouth. Which of the following is the most likely diagnosis?

QID: 104431
1

Migraine headache

63%

(38/60)

2

Subarachnoid hemorrhage

3%

(2/60)

3

Temporal arteritis

12%

(7/60)

4

Temporomandibular joint dysfunction

13%

(8/60)

5

Tension headache

7%

(4/60)

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Evidence (2)
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