TMJ Dysfunction

Orofacial pain differential

Dental: caries; abscess; tooth eruption. Ear: acute otitis media/externa; mastoiditis; eustachian tube dysfunction. Headaches: tension, migraine, cluster. Neurological: trigeminal neuralgia; post-herpetic neuralgia; glossopharyngeal neuralgia. Inflammatory: temporal arteritis; rheumatoid arthritis; SLE; parotitis. Trauma.

Condition

Pain involving the TMJ and surrounding structures, and dysfunction of the joint itself. Divided into myofascial causes (stress, bruxism, teeth grinding, abnormal posture) and intra-articular causes (osteoarthritis, capsular inflammation, hypermobility, traumatic injury).

Demographics: common — 60–70% of the population have some signs, but only 5–12% have symptomatic disease needing treatment. Peak incidence 20–40 years; women affected 4× more than men. Commonly associated with depression, anxiety, fibromyalgia, and other chronic pain conditions.

History

Pain in and around the TMJ, worsened by joint use. Locking, clicking, and crepitus are commonly reported. Headaches may be associated; sometimes tinnitus, aural fullness, vertigo, or subjective hearing impairment.

Examination

Tenderness on TMJ palpation, clicking. Pain on jaw movement, headache, and referred pain suggest a muscular problem. Examination should include otoscopy, an oral examination, and palpation of the neck muscles.

Investigations

Not usually needed; consider X-ray if osteoarthritis is suspected.

Management

~40% of cases resolve spontaneously.

Non-pharmacological: reassurance; jaw rest; soft diet; warm compress over the region; improving sleep, anxiety, and stress.

Pharmacological: NSAIDs (not topical diclofenac); benzodiazepines for recurrent muscular spasm; amitriptyline. Avoid SSRIs/SNRIs/MAOIs and opioids.

A 6–8 week treatment trial before referral is reasonable.

Red flags for specialist referral

Persistent and worsening pain; trismus; cranial nerve abnormalities; neurological dysfunction; concurrent infection; systemic illness; asymmetrical neck/facial swelling; unilateral hearing loss; vestibular dysfunction; new or unilateral tinnitus.