Review Question - QID 108860

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Temporomandibular Disorders Epidemiology Risk factors QID: 108860 (M2.ET.17.4753)

QID 108860 (Type "108860" in App Search)

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?

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Nighttime bite guard

65%

59/91

Plain radiograph of the jaw

27%

25/91

MRI of the brain

5/91

Surgical intervention

1/91

Electrocardiogram

0/91

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This patient has jaw pain worse in the morning, nighttime bruxism, and jaw clicking on exam, most consistent with temporomandibular joint dysfunction (TMJ). The next best step in management is use of a nighttime bite guard.

TMJ is a common cause of jaw pain, especially in women. Dull, deep pain that is worse on chewing and in the mornings as well as radiation to the periorbital area or back or the neck is highly suggestive of TMJ. Patients may also have decreased range of jaw opening. Nighttime bite guard is the first-line treatment for TMJ, with imaging and surgery reserved only for refractory cases that fail conservative management.

Incorrect Answers:
Answer 2: Plain radiograph of the jaw is typically reserved for patients who have jaw pain that does not respond to a nighttime bite guard. It may identify articular degeneration or bony tumors, but it is not indicated for uncomplicated TMJ.

Answer 3: MRI of the brain can be helpful for diagnosing conditions such as multiple sclerosis (MS), which would appear as white matter demyelinating lesions. Bilateral trigeminal neuralgia can be a clue for MS in a young female, but this would present with sharp transient pains rather than the dull ache this patient describes.

Answer 4: Surgical intervention such as arthrocentesis or reconstructive procedures are reserved for TMJ that is refractory to conservative management and is felt to be due to structural pathology. It would be inappropriate to operate on this patient without first trying a nighttime bite guard.

Answer 5: Electrocardiogram would be useful if acute coronary syndrome (ACS) were suspected in this patient. Although ACS could cause jaw pain (and often presents atypically in women) and she does have a family history of early myocardial infarction, this patient’s more chronic symptoms and physical exam suggest TMJ instead.

Bullet Summary:
Nighttime bite guard is the first-line therapy for temporomandibular joint dysfunction (TMJ), with surgery indicated only if symptoms are refractory.

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