Topic Overview
What are temporomandibular (TM) disorders?
Temporomandibular (TM) disorders is the name given to several problems with jaw
movement and pain in and around the
jaw joints.
You may also hear TM disorders called TMJ, TMD, or
TM problems.
The jaw joints, or
temporomandibular (TM) joints, connect the lower
jawbone (mandible) to the skull. These flexible joints are used more than any
other joint in the body. They allow the jaw to open and close for talking,
chewing, swallowing, yawning, and other movements.
Many people
have problems with jaw movement and pain in and around the jaw joints at some
time during their lives. These joint and muscle problems are complex. So
finding the right diagnosis and treatment of TM disorders may take some
time.
What are the symptoms?
TM disorders can affect the
jaw and jaw joint as well as muscles in the face, shoulder, head, and neck.
Common symptoms include joint pain, muscle pain, headaches, joint sounds,
trouble with fully opening the mouth, and jaw locking.
In most
cases, symptoms of TM disorders are mild. They tend to come and go without
getting worse and usually go away without a doctor’s care.
Some
people who have TM disorders develop long-lasting (chronic) symptoms. Chronic pain or difficulty moving the jaw may affect talking, eating, and
swallowing. This may affect a person's overall sense of well-being.
See a picture of
areas often affected by TM disorder pain.
What causes TM disorders?
The most common cause of
TM disorder symptoms is muscle tension, often triggered by stress. When you are
under stress, you may be in the habit of clenching or grinding your teeth.
These habits can tire the jaw muscles and lead to a cycle of muscle spasm,
tissue damage, pain, sore muscles, and more spasm.
TM disorders
can start when there is a problem with the joint itself, such as:
- An injury to the joint or the tissues around
it.
- Problems with how the joint is shaped.
- Joint
diseases, such as
osteoarthritis or
rheumatoid arthritis.
- The articular disc
that cushions the joint shifts out of place.
How is a TM disorder diagnosed?
Although there is
no one way to identify a TM disorder, your doctor can most likely check your
condition with a physical exam and by asking questions about your past health.
In some cases, an
X-ray,
CT scan, or
MRI is also used to check for bone or soft tissue
problems related to symptoms of TM disorder.
How is it treated?
TM disorder symptoms usually go
away without treatment. Simple home treatment can often relieve mild jaw pain.
There are things you can do at first to reduce pain.
- Rest your jaw joint.
- Use
medicines for a short time, to reduce swelling or relax muscles.
-
Put either an ice pack or a warm, moist cloth on your jaw for 15 minutes
several times a day if it makes your jaw feel better. Or you can switch back
and forth between moist heat and cold. Gently open and close your mouth while
you use the ice pack or heat. But don't use heat if your jaw is swollen. Use
only ice until the swelling is gone.
- Eat soft foods. And avoid
chewy foods and chewing gum.
Getting physical therapy and learning ways to reduce
stress may also help to reduce pain and TM joint problems. Continue to use some
of these methods over time to prevent and manage symptoms that might come back.
If your pain is chronic or severe or is caused by problems with how the joint
is shaped, your doctor may recommend other treatments.
Splints,
also called bite plates, are a common dental treatment for TM disorders. Splints
are usually clear pieces of plastic that fit between the upper and lower teeth.
They help reduce grinding and clenching. Splints are used for a short time so
that they do not cause permanent changes in the teeth or jaw.
Before you try treatments such as surgery or reshaping or shaving down
the teeth, think it over. These treatments cannot be reversed and can even
damage the TM joint.
For most people, surgery is not used to treat
TM disorders. Surgery has few benefits, and there is the chance of causing more
serious problems. You and your doctor can carefully weigh a decision to have
surgery. Talking with another doctor to get a second opinion can also help you
make your decision.
Chronic pain can lead to
depression,
anxiety, and other problems. If you have chronic pain,
talk to your doctor about medicine and mental exercises to manage the pain.
Give special attention to treating any related anxiety or depression.
Frequently Asked Questions
|
Learning about temporomandibular (TM) disorder:
|
|
|
Being diagnosed:
|
|
|
Getting treatment:
|
|
|
Ongoing concerns:
|
|
Cause
Temporomandibular (TM) disorders can result from a single cause or, more commonly, a
combination of causes.
The main causes of TM disorders
include:
- Muscle tension (tightness) and spasm. Muscle
tension in the jaw, face, head, neck, and shoulders may make your jaw feel
achy, stiff, and painful, especially when moving your jaw. Muscle tension may
be:
- Problems in the internal structure of the joint,
such as:
In many cases, TM
disorder symptoms appear to be caused by both muscle tension (tightness) and
joint dysfunction. It is not always clear which came first. For example,
osteoarthritis can cause changes in the joint, which may then bring on muscle
spasms. Conversely, muscle spasms over time hinder jaw function and can
eventually cause osteoarthritis in the jaw joint. A similar relationship
appears to exist between muscle tension and disc displacement within the
joint.
Orthodontic treatment and
malocclusion do not seem to trigger TM disorders or make them
worse.
When jaw joint problems are caused by diseases such as
rheumatoid arthritis, treatment for that condition is important. Many
other conditions cause symptoms similar to those of TM disorders, such as
migraine headaches and infections.
Symptoms
Symptoms of
temporomandibular (TM) disorders are usually mild and
temporary and typically do not get worse with time. Common symptoms
include:
- Joint pain when the jaw is moving, as when
opening the mouth widely, chewing, or yawning. Such pain can occur:
- Usually on one side of the jaw, but it can
be on both sides.
- Either gradually or suddenly, as when biting
down on something hard or following a blow to the jaw.
- Muscle pain or tenderness in the face, ear, head,
neck, or shoulders.
- Headaches. In children with TM disorders, these
are often related to grinding the teeth (bruxism).
- Clicking, popping, cracking, or
grating that is painful and occurs when opening the jaw (may be a sign of
disc displacement). Clicking or popping noises without pain are common and do
not require treatment.
- The jaw locking in an open or closed
position or not opening wide (disc displacement). If the jaw locks for more
than a few moments, a muscle spasm usually follows.
See a picture of
areas typically affected by TM disorder pain.
Sometimes pain
around the ear, with pressure or ringing in the ears (tinnitus), develops with
TM disorders. Some people with these symptoms report that they also have
hearing loss, although test results show that their hearing is normal.
Symptoms often go away on their own, and they may recur over time without
getting much better or worse. Occasional discomfort in the jaw joint or chewing
muscles is quite common and usually is not a cause for concern.
Chronic pain
Some people with TM disorders have
facial or jaw pain that lasts a long time (chronic). These people may try
several treatment methods and have little improvement. While treatment can
appear successful to a doctor, pain lingers. This may be due to the lasting
psychological and biological impact of
chronic pain, which can lead to or intensify
depression,
anxiety, a sense of helplessness, and biochemical
changes in the body that perpetuate pain.
What Happens
The course of
temporomandibular (TM) disorders caused by muscle
tension varies depending on the cause of the muscle tension.
- If muscle tension is related to a one-time
overuse injury (such as holding your mouth open for a long time during a dental
exam), the pain and discomfort may go away without treatment.
- If there is long-lasting (chronic) muscle tension
due to stress, anxiety, an injury or blow to the jaw, or habits like grinding
the teeth during sleep, treatment (including changing certain habits) may
relieve pain and discomfort. If chronic muscle tension is not treated, it may
gradually cause changes in the joint structure or
osteoarthritis.
TM disorders caused by problems in the
structure of the jaw joint may:
- Respond well to nonsurgical treatment, if
treated early.
- Get worse, if not treated. Long-term consequences
include injury to the disc or other tissues in the joint, arthritis, or chronic
pain.
Chronic pain
In some cases, TM disorders can be
extremely painful and disabling and last a long time. Such
chronic pain can affect a person's overall quality of
life by increasing stress, making it hard to do a job, and
interfering with personal life.
Depression and
anxiety are common results of chronic pain. In these
cases, it is especially important to seek treatment for TM disorder pain and
for related depression and anxiety.
What Increases Your Risk
Risk factors for
temporomandibular (TM) disorders include:
- Stress and anxiety, which can cause facial and
jaw muscle tension.
- Repetitive habits, such as grinding your teeth
(bruxism), clenching your teeth, excessive gum chewing,
eating hard or chewy foods, and nail biting.
- Habits that can cause
muscle tension, such as sleeping on one side of your face or with your mouth
open, opening your mouth wide when yawning or singing, or holding your head up
by cradling your jaw in your hand.
- Injury to the jaw or head. TM
disorders can result from a direct blow to the jaw, chin, or head;
whiplash to the head or neck; overstretching the jaw
during dental work or surgery; or other injuries that may lead to joint damage
or muscle tension.
- Age and gender. TM disorders primarily affect
people between the ages of 20 and 50. 1Women are more likely to report symptoms of TM disorder than men.
In the past,
malocclusion and
orthodontics were thought to cause or contribute to TM
disorders. Similarly, orthodontics have been used to treat TM disorders.
Current research suggests that orthodontic treatment and
malocclusion do not trigger TM disorders or make them
worse.2
When To Call a Doctor
Call your dentist or doctor immediately if you have had an
injury to your jaw or face and:
- Your jaw is very painful.
- Your jaw
is locked open or shut, or you are unable to move your jaw easily or smoothly
(a sign of
disc displacement, dislocation, or fracture).
- Your jaw appears to
be deformed or swollen.
- There is swelling in the sides of your
face.
- Your teeth no longer fit together normally when biting down
(malocclusion).
- A severe headache or neck ache strikes suddenly,
without apparent cause, or is different from previous headaches.
Call your dentist or doctor if
you:
- Have pain when moving your jaw (biting,
chewing, swallowing, talking, or yawning) that is not getting better after 2
weeks of home treatment.
- Have had jaw pain for a long time
(chronic).
- Have anxiety, stress, or work-related problems caused by
your jaw discomfort and pain.
- Continue to have symptoms (such as
pain with clicking or cracking sounds or your jaw locks) after 2 weeks of home
treatment.
- Notice a change in the way your teeth fit together when
you close your mouth.
Watchful Waiting
Mild symptoms of TM disorders usually respond to
home treatment. Try home treatment for at least 2 to 4 weeks before considering
other types of treatment. For most people, TM disorder discomfort will
eventually go away whether it is treated or not.
Who To See
Your treatment for
temporomandibular (TM) disorder may involve several
different health professionals.
Initial evaluation can be done by
a:
Further diagnosis and treatment may be done by a:
- Dentist who specializes in treating TM
disorders.
- Physical therapist.
- Facial pain
expert.
- Oral and maxillofacial surgeon.
Additional treatment may be provided by:
If a doctor suggests that you try a
treatment that might make permanent changes to your jaw, be sure to get a second opinion.
Most health and dental
insurance plans do not cover TM disorder diagnosis and treatment. Because some
tests and treatments are quite expensive, you may want to verify your insurance
coverage before incurring expenses.
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Exams and Tests
Currently there is no widely accepted
standard test for identifying the cause of
temporomandibular (TM) disorders. But your dentist or
primary care doctor will most likely be able to accurately diagnose your
condition with information from a
medical history and physical exam.
Most
TM disorders are caused or made worse by muscle tension (tightness). Expect
your doctor to suggest treatment that does not involve surgery or
permanent changes to the jaw (conservative treatment) to relieve your jaw pain,
muscle tension, and TM joint problems.
If you have sudden pain
after a facial or jaw injury, your doctor is likely to order some
type of imaging test, such as an X-ray, a CT scan, or magnetic resonance
imaging (MRI).
If conservative treatment has not worked
If
conservative treatment has not worked and your jaw is locking in place (a sign
of disc displacement), your pain is severe or chronic, or
you have other medical problems, such as
rheumatoid arthritis, other tests may be needed. These
tests are usually done only if knowing their results could change your
recommended treatment plan.
If your symptoms persist after the
first period of treatment, your doctor may begin to look for
problems in the jaw joint structure. Other tests may include:
- X-ray. This
test can confirm whether the bones are worn away, broken, or disfigured. If
disc displacement is suspected, X-rays may be helpful to show the size of the
joint space. A narrow joint space can be a sign that the disc is
affected.
- Magnetic resonance imaging (MRI). A
view of the soft tissues (ligaments, muscles, and articular disc) is useful in
showing disc displacement or damage. Although expensive, MRI is thought to be the
most effective imaging technique for assessing TM disorders that may involve
disc problems.
Treatment Overview
The goal of treatment for
temporomandibular (TM) disorders is to relieve pain in
the jaw and restore normal jaw movement and function. Several treatment
approaches are effective. Often, simple home treatment measures can
successfully relieve jaw pain without medical or dental treatment. For chronic,
muscle-related TM disorders, standard medical care can include muscle
relaxation measures,
biofeedback, stress management, or
cognitive-behavioral therapy.
The
National Institutes of Health (NIH) recommends conservative,
noninvasive treatment measures for TM disorders. For
first-time treatment of TM disorder symptoms, the NIH recommends avoiding
invasive or irreversible procedures, such as surgery or dental/orthodontic
work.3
The most common dental
treatment for TM disorders is using splints or bite plates for a short period of
time. Splints—called occlusal splints—are usually clear, plastic appliances
that fit between the upper and lower teeth. They help reduce grinding and
clenching (bruxism) and, in turn, can relieve
muscle tension and pain. This may allow a displaced disc to return to its
normal position. Splints are used over short periods of time so that they do
not cause permanent changes in the teeth or jaw.
Temporarily avoid
dental work (such as crowns, bridges, or shaving down the teeth) and
orthodontic treatments involving permanent changes to
the jaw. At best, these measures may not work any better than conservative
treatments. At worst, they can cause irreversible damage. If your doctor recommends surgery or other treatment that involves permanent
changes, be sure to get a second opinion before you start treatment.
TM disorder: Should I have surgery for jaw pain?
See the Home Treatment, Other Treatment, and Surgery
sections of this topic for specific treatment options.
What To Think About
Often, structural problems in
the jaw, such as
disc displacement, can be improved with conservative (nonsurgical) treatment,
especially when they are treated early.
In the past, teeth not
fitting together properly (malocclusion) was considered to be a
cause of TM disorders, and braces (orthodontics) were used to treat them.
Current research suggests that orthodontic treatment and
malocclusion do not trigger TM disorders or make them
worse.2, 2
Most health and dental insurance plans do not cover TM disorders. Check
with your insurance provider to find out whether you are covered before
incurring medical or dental expenses related to diagnosis or treatment.
Prevention
To prevent
temporomandibular (TM) disorders, try to reduce muscle
tension in your jaw. You can reduce muscle tension with these steps:
- Relax. If you have a lot of stress and anxiety
in your life, try relaxation techniques. See the topic
Stress Management.
- Learn to recognize when
you are clenching your teeth. Practice keeping your teeth apart, bringing them
together only when swallowing or eating. When driving, avoid clenching the
wheel with both hands, because often your teeth will be clenched as
well.
- Do not overuse and stress your jaw muscles. Avoid constantly
chewing gum, biting your nails, resting your chin on your hand, or cradling the
telephone receiver between your shoulder and jaw.
- Change your diet.
Eat softer foods, and use both sides of your mouth to chew your food. Avoid
hard or chewy foods, such as popcorn, apples, carrots, taffy, hard breads, and
bagels.
- Maintain good posture. Poor posture may disturb the natural
alignment of your facial bones and muscles, causing pain.
In the past, various procedures such as dental restoration
and orthodontic treatment were used to prevent joint sounds from developing
into TM disorders. Such "preventive" measures are not only unneeded but also
potentially damaging to a joint that may never become painful on its
own.
See the Home Treatment section of this topic for other steps
to prevent or reduce muscle tension in your jaw.
Home Treatment
If your
temporomandibular (TM) disorder symptoms are mild, try
home treatment for at least 2 weeks. If your symptoms get worse during this
time, call your doctor or dentist.
Home treatment
involves reducing your stress, resting your jaw (by eating only soft or pureed
foods), taking steps to reduce pain, and exercising your jaw.
To
help relieve pain and restore jaw function:
- Put either an ice pack or a warm, moist cloth on your jaw for 15
minutes several times a day if it makes your jaw feel better. Or you can switch
back and forth between moist heat and cold. Gently open and close your mouth
while you use the ice pack or heat. But don't use heat if your jaw is swollen.
Use only ice until the swelling is gone.
- Change your diet to
decrease jaw strain.
- Modify your jaw movements to keep your
jaw muscles relaxed.
- Do jaw exercises as prescribed by your doctor or physical
therapist.
- Try comfort measures such as moist heat, ice, or nonsteroidal
anti-inflammatory drugs (NSAIDs).
- Reduce stress. Many people tend to clench or tighten their muscles when they
are under stress of any kind.
- Change your body mechanics, such as by using good
posture for sitting and standing.
If you have been diagnosed with a TM disorder, these home
treatment measures will optimize the treatments prescribed by your doctor or dentist, such as a
splint therapy or physical therapy.
Medications
You can use medicine to relieve the
pain of a
temporomandibular (TM) disorder. Short-term use of
nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, muscle relaxants, or
antidepressant medicines can relieve or reduce
inflammation, control pain, and relax the jaw muscles.
Medication Choices
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat inflammation and pain. These are the most
commonly used medicines for TM disorders.
- Narcotic pain relievers (such as acetaminophen with
codeine or hydrocodone) are used in some cases of acute, severe pain. Because
narcotics are addictive, they are usually not taken long
term.
- Muscle relaxants, such as diazepam (Valium) or
cyclobenzaprine (Flexeril), are used in some cases of acute pain or prolonged
muscle spasm. Because they are addictive, sedating, and can cause depression or
make it worse, muscle relaxants should be taken at the lowest possible dose and
are usually not used long term.
- Low doses of tricyclic antidepressants, such as amitriptyline,
can effectively relieve chronic pain and make treatment more successful.4 These
medicines have also been helpful for improving disrupted sleep patterns,
which can cause
bruxism.
What To Think About
Nonsteroidal anti-inflammatory
drugs (NSAIDs) do not cure TM disorders, but they may reduce pain and
inflammation, which allows you to do prescribed jaw exercises that can start
the healing process. NSAIDs may be prescribed on a regular basis for 1 to 2
weeks to help reduce inflammation even though the pain has subsided.
Your doctor may prescribe an antidepressant, not necessarily because you
suffer from depression but to help treat chronic pain or nighttime
bruxism.
Surgery
Surgery is rarely used to treat
temporomandibular (TM) disorders. Surgical treatment
does not guarantee a cure and can further damage the temporomandibular joint.
Because most TM disorders can be treated nonsurgically, most doctors believe that surgery should be the last option tried and should
be avoided if possible.
Surgery may be a treatment option for you
if both of the following apply:
- Other treatments have failed, and chronic jaw
pain and dysfunction have become disabling.
- There are specific,
severe structural problems in the jaw joint. These include scar tissue in the
joint area, problems with bone alignment, broken or degenerated bones, and
occasionally
disc displacement or perforation.
The goals of surgery for temporomandibular (TM) disorders
are to:
- Relieve pain in the jaw
joint.
- Correct any structural problems.
- Restore normal
jaw function.
TM disorder: Should I have surgery for jaw pain?
Surgery Choices
- Arthrocentesis. This is not a true
surgery, since there is no incision. But it is an invasive procedure performed
by an oral and maxillofacial surgeon. Arthrocentesis to wash out
the joint area (lavage) seems to work for people who have severe closed
lock of the temporomandibular joint.5
Surgery may include:
- Arthroscopic
procedures, including washing out the joint area (lavage), cutting or removing
scar tissue that is blocking joint movement (lysis), cutting tissue that has
shortened and is impeding joint function, or shaving part of the
disc.
- Open joint arthroplasty, used for disabling joint
problems that aren't easily reached or viewed arthroscopically.
Another type of surgery, called total joint replacement,
is rarely done. It has sometimes resulted in permanent jaw damage. Total joint
replacement replaces the jaw joint with artificial parts. In some cases the
artificial parts have not worked correctly or have broken. The available
technology for this surgery is still considered to be experimental and
risky.
What To Think About
Further pain complications or
joint dysfunction can result from temporomandibular joint surgery.
Surgery is not necessary in most
cases of disc displacement.5 Splint therapy (a
dental treatment), jaw rest, and physical therapy, including moist heat and jaw
exercises followed by an ice pack, can work very well for treating this
condition. If this and other nonsurgical treatment to relax the muscles are not
successful, arthrocentesis may effectively treat your condition.
If you are thinking about surgery, get a second opinion on your condition
and treatment.
Other Treatment
Many types of treatment can
successfully relieve
temporomandibular (TM) disorder symptoms. Different
doctors will suggest different treatments, any of which may work
to relieve jaw and facial pain.
If a doctor
recommends that you try a treatment that might make permanent changes to your
jaw or teeth, get a second opinion.
Other Treatment Choices
Depending on your condition, one of the following choices
may be more effective than another. Safe options for treatment of TM disorder
include:
Complementary Medicine
Treatments considered
safe and effective for some people include:
What To Think About
Many different types of
treatment for temporomandibular (TM) disorders have potential for successfully
relieving your condition. If your problem is linked to muscle tension, any
treatment that helps you relax your jaw muscles with no adverse effects is
likely to be helpful. Different treatments work for different people.
Treatments vary greatly in safety, cost, and how well they work.
Other Places To Get Help
Organizations
| Academy of General Dentistry |
| 211 East Chicago Avenue |
| Suite 900 |
| Chicago, Illinois 60611-6660 |
| Phone: |
1-888-243-3368 |
| Fax: |
(312) 440-0559 |
| Web Address: |
www.knowyourteeth.com |
| |
|
The Academy of General Dentistry is a nonprofit
organization dedicated to helping dentists stay up to date in the dental
profession through continuing education. The organization also provides
consumers with information on oral health care.
|
|
| National Institute of Dental and Craniofacial Research
(NIDCR) |
| National Institutes of Health |
| Bethesda, MD 20892-2190 |
| Phone: |
1-866-232-4528 toll-free |
| Fax: |
(301) 480-4098 |
| Email: |
nidcrinfo@mail.nih.gov |
| Web Address: |
www.nidcr.nih.gov |
| |
|
The National Institute of Dental and Craniofacial Research (NIDCR)
is a governmental agency that provides information about oral, dental, and
craniofacial health. By conducting and supporting research, the NIDCR aims to
promote health, prevent diseases and conditions, and develop new diagnostics
and therapeutics.
|
|
References
Citations
- Scrivani SJ, et al. (2008). Temporomandibular disorders. New England Journal of Medicine, 359(25): 2693–2705.
- Koh H, Robinson PG (2004). Occlusal adjustment for treating and preventing temporomandibular joint disorders. Journal of Oral Rehabilitation, 31(4): 287–292.
- National Institutes of Health (1996). Management of temporomandibular disorders. Technology Assessment Conference Statement, April 29–May 1, 1996. Available online: http://consensus.nih.gov/1996/1996TemporomandibularDisorders018PDF.pdf.
- Rizatti-Barbpsa CM, et al. (2003). Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders. Journal of Craniomandibular Practice, 21(3): 221–225.
- Tucker MR, et al. (2008). Management of
temporomandibular disorders. In JR Hupp et al., eds., Contemporary Oral and Maxillofacial Surgery, 5th ed., pp.
629–649. St. Louis: Mosby Elsevier.
Other Works Consulted
- American Society of Temporomandibular Joint Surgeons (2003). Guidelines for diagnosis and management of disorders involving temporomandibular joint and related musculoskeletal structures. Cranio, 21(1): 68–76.
- Ohrbach R, Burgess J (2009). Temporomandibular
disorders and orofacial pain. In RE Rakel, ET Bope, eds., Conn's Current Therapy 2009, pp. 988–994. Philadelphia: Saunders Elsevier.
Credits
| By |
Healthwise Staff |
| Primary Medical Reviewer |
Kathleen Romito, MD - Family Medicine |
| Specialist Medical Reviewer |
Steven K. Patterson, BS, DDS, MPH - Dentistry |
| Last Revised |
May 4, 2010 |
