TMJ & Facial Pain


Temporomandibular Disorder (TMD) is a broad term describing facial pain associated with the temporomandibular joint (jaw joints) and muscles that are used to open and close the mouth.  TMD can be broken down into three fundamental conditions:

  1. Myofacial Pain
  2. Internal Derangement
  3. Degenerative Joint Disease

What is myofacial pain?

Myofacial Pain is rather a simple concept. It is pain of muscles. Patients may experience stiffness and pain secondary to spasm of usually the larger muscles of the head and neck that are used to open and close your jaw. Tension headache is a form of myofacial pain where patients feel pain at the forehead and temple muscles. This type of pain is usually self-limiting and can be resolved without surgery. The usual symptoms can include but are not necessarily limited to the following: jaw pain, difficulty with jaw opening, earaches, headaches, pain behind the eyes, jaw joint popping and clicking, dizziness, and difficulty chewing food or closing your teeth together.  


What is internal derangement?

Internal derangement of TMJ indicates an abnormal relationship of the disc in your jaw joint. One can describe it as a slipped disc that does not allow proper functioning of the jaw joint. Patients with internal derangement of TMJ may experience painful/loud clicking or popping and are unable to open their mouth fully.  


Degenerative Joint Disease

Remember, our jaw joints are like any other joints in the body. Therefore, if you have generalized joint disease or problems, your jaw joints may be affected.

Osteoarthritis is a more common form of degenerative joint disease seen in the temporomandibular joint. Most of us are familiar with osteoarthritis as a gradual development of joint pain, stiffness and limitation of motion and usually correlates to aging and the wear and tear of a functional joint. However, osteoarthritis of TMJ can trigger in younger patients with no other significant medical history or other arthritis. This type of osteoarthritis is described as secondary osteoarthritis.

Secondary osteoarthritis describes joint degeneration secondary to multiple causes which include trauma (motor vehicle accident, grinding teeth), crystal deposition disease(gout, pseudogout), infection, metabolic or endocrine disorders, congenital anomalies, etc.  


How do I know which condition I have?

Patients can present with one more of the above conditions. Therefore, it is important that you are evaluated by an oral and maxillofacial surgeon with expertise in treating temporomandibular disorders.

History and physical exam are always very important. Giving your doctor a thorough history can aid in your diagnosis tremendously.  


Do I need to have X-rays done?

The doctor will often order a radiographic study such as a panoramic radiograph. This can be perfomed at the office. If there is a suspicion of joint problems, your doctor will order an MRI (magnetic resonance imaging). This is usually scheduled at a hospital.  


Treatment

Currently, it is recommended that most TMD be initially managed with conservative therapy. Conservative therapy means maintaining a soft food diet for several weeks, taking non-steroidal anti-inflammatory medications (e.g. motrin, alleve), using warm compresses and wearing a biteplate. Your doctor may refer you to a physical therapist who can work with you about improving head posture and passive jaw exercises to improve jaw tension and pain.

If symptoms persist or progress and the pain/dysfunction is localized to the joint, surgery should be considered.

Surgical interventions for TMD can range from simply washing the joint space (arthrocentesis), visualizing the joint space with a small camera and removing adhesions (arthroscopy), to making a small incision most often in a skin crease in front of the ear to repair or reposition a displaced disc (open arthroplasty). If the disc is severely diseased, it may be removed during open arthroplasty (menisectomy).

Patients with significant dentofacial deformity and significant temporomandibular dysfunction may require braces and orthognathic (jaw) surgery.

Finally, patients with history of multiple jaw surgeries including teflon-proplast implants and ankylosis (fusion of the jaw joint to the skull) of the joints may require total joint replacement.  


What type of surgery will I need?

The proper surgical treatment is dependent on the patient's history, age and clinical exam. Surgery should not ever be taken lightly and should not be considered a panacea. As you have learned from our discussion above, there are certain forms of TMD, specifically myofacial pain, that should never be treated with surgery. Often, many patients have underlying myofacial pain which needs to be treated first with conservative treatment. On the other hand, surgery can mean tremendous relief in the patient suffering from intractable anatomical disease or internal derangement (when the biomechanics of our joints are functioning improperly). If you have pain or dysfunction of the TMJ, you should be evaluated by an oral & maxillofacial surgeon with an expertise in managing TMD.  


How long will I need to stay in hospital?

Surgery of the TMJ is almost always performed in a formal operating room as an ambulatory procedure. It is rare today, that patients require an overnight admission. Most patients will easily return to work in three to five days and suffer only moderate discomfort in the early post-operative period. All are generally restricted to a soft diet for six to eight weeks.  


Other Considerations

The head and neck is a condensed complicated map of many anatomic structures. Often, pain of the TMJ may be a referred pain from near by structures. Appropriate referrals to general dentists, specialty dentists, otolaryngologists or neurologists may be necessary.  


Conclusion

The National Institute of Health estimates that 10 million Americans have painful TMJ and dysfunction. The majority are self-limiting or respond to conservative therapy. 5-10% have significant impairment that require surgical treatment.