Temporomandibular joint dysfunction

The temporomandibular joints (TMJ) connect your lower jaw to your skull. There are two matching joints -- one on each side of your head, located just in front of your ears. The abbreviation "TMJ" refers to the joint but is often used to refer to any disorders or symptoms of this region. Such problems include popping sounds in the jaw, inability to fully open the mouth, jaw pain, headaches, earaches, toothaches, and various other types of facial pain.

Signs and Symptoms

The following signs and symptoms often accompany TMJ dysfunction:

• Pain, particularly in the chewing muscles or jaw joint
• Limited movement or locking of the jaw
• Radiating pain in the face, neck, or shoulders, or near the ear
• Clicking, popping, or grating sounds when opening or closing the mouth
• Difficulty chewing
• Headache
• A sudden, major change in the way the upper and lower teeth fit together
• Also, sometimes earaches, dizziness, and hearing problems

What Causes It?

Sometimes TMJ dysfunction can be caused by a severe injury, such as a heavy blow, to the jaw or temporomandibular joint. But in other cases there is no identifiable cause. Other possible causes include:

• A bad bite (malocclusion)
• Orthodontic treatment, such as braces and the use of headgear
• Jaw clicking, which is more likely the sign of a displaced disk
• Poor posture
• Stress or anxiety, which may cause or aggravate TMJ dysfunction. People with TMJ dysfunction often clench or grind their teeth (bruxism) at night, which can tire the jaw muscles and lead to pain.

Who's Most At Risk?

The following risk factors are associated with TMJ dysfunction.

• Gender -- women seek treatment two times more than men
• Age -- people ages 30 - 50 are most often affected
• Nutritional or metabolic disorders
• Grinding teeth, clenching jaw
• Malocclusion (bad bite)
• High stress levels

What to Expect at Your Provider's Office

If you are experiencing symptoms associated with TMJ dysfunction, you should see your doctor or dentist. They can help make a diagnosis and guide you in determining which treatment or combination of therapies will work best for you.

Your health care provider will check muscles in the area of the TMJ, look for asymmetry or inflammation in your face, listen for joint clicking or scraping sounds, test the range of motion in your jaw, and examine your teeth for evidence of jaw clenching or teeth grinding. If you're having any neurological symptoms, such as numbness, your health care provider will give you a neurological examination. An x-ray, computerized tomography scan, or magnetic resonance imaging scan may be used if there is evidence of degenerative disease or disk problems.

Treatment Options

Prevention

Reducing stress and keeping yourself from grinding your teeth or clenching your jaw may help prevent TMJ dysfunction or lessen the symptoms.

Treatment Plan

Some health care providers consider TMJ dysfunction a medical condition while others consider it a dental problem. Your doctor may ask you to change your eating habits -- to cut foods into small pieces, avoid excess chewing, stop chewing gum -- and give you exercises that stretch the muscles around your jaw. If your bite is out of alignment, your dentist may suggest you wear a biteplate over your teeth to help bring your upper and lower jaw into alignment. If you grind your teeth in your sleep, you may be asked to wear a night guard over your teeth. Finally, your doctor may suggest stress reduction techniques or cognitive behavioral therapy that can help you manage anxiety and tension.

Drug Therapies

Your provider may prescribe any of the following medications:

• Analgesics -- aspirin or nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin)
• Minor tranquilizers or muscle relaxants at bedtime to reduce spasms and pain
• Injections of a local anesthetic
• Corticosteroid injections, for severe cases

Surgical and Other Procedures

When all other measures have failed, surgery may be necessary.

Complementary and Alternative Therapies

A comprehensive treatment plan for TMJ dysfunction may include a range of complementary and alternative therapies.

Nutrition and Supplements

The following nutritional tips may help prevent or reduce symptoms of TMJ dysfunction:

• Eat soft foods high in flavonoids to provide antioxidants to decrease joint pain.
• Avoid saturated fats, fried foods, and caffeine, all of which increase inflammation.
• Avoid chewing gum.

Potentially beneficial supplements include:

• Glucosamine (500 mg three times per day) seems to lessen pain and may help rebuild cartilage in the joint, which helps improve range of motion. Glucosamine is sometimes combined with chondroitin sulfate (400 mg three times per day).
• Vitamin C (500 mg two times per day) is also used by the body to make cartilage and may improve range of motion in your joints, including your jaw.
• Calcium (250 mg two times per day) and magnesium (125 mg two times per day) are sometimes suggested to help the jaw muscle relax. Magnesium interacts with several medications, herbs, and supplements, so be sure to tell your doctor before you take it.

Herbs

• Cramp bark (Viburnum opulus) and lobelia (Lobelia inflata) are antispasmodic. Rub 5 drops tincture of each herb into joint. Do not apply to broken skin.

Homeopathy

The appropriate homeopathic treatment for TMJ dysfunction depends on the individual's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for each individual. Some remedies commonly used by professional homeopaths to treat TMJ dysfunction include:

• Causticum --for burning pains
• Hypericum perforatum --for sharp shooting pains
• Ignatia -- for tension in the jaw
• Kalmia --for face pain, especially with other joint pains or arthritis
• Magnesia phosphorica -- for muscle cramps
• Rhus toxicodendron --for pains that feel better in the morning and in dry weather, and worse after movement or in wet weather
• Ruta graveolens -- for pains from overuse or injury

Physical Medicine

Contrast hydrotherapy -- alternating hot- and cold-water applications -- may decrease inflammation, provide pain relief, and enhance healing. Use hot packs and ice wrapped in a clean, soft cloth and apply to area. Alternate 3 minutes hot with 1 minute cold and repeat three times for one set. Do two to five sets per day.

Acupuncture

Very good evidence suggests acupuncture can treat TMJ dysfunction. Several well-designed trials found that acupuncture can help provide long-term pain relief for this condition. In treating TMJ dysfunction, acupuncturists often find a deficiency of qi in the liver meridian and an excess of qi in the gallbladder meridian. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) may enhance the therapy.

Chiropractic

No well-designed studies have evaluated the effect of chiropractic on individuals with TMJ dysfunction, but chiropractors and some patients report that manipulation of the TMJ and adjacent areas in the upper spine may improve symptoms of the condition. It is believed, in these cases, that manipulation restores movement to the TMJ.

Craniosacral Therapy

This therapy is a very gentle form of body work in which a practitioner uses their hands to release restrictions in the craniosacral system (the fluid and membranes surrounding the spine and brain). Although studies are few, anecdotal evidence suggests some people feel improvement after craniosacral therapy. Because there is no single agency that certifies practitioners in this therapy, talk to your provider about the level of training they have received. You can also interview several practitioners before deciding which one is right for you.

Massage

Certain types of massage techniques and chiropractic manipulation may help decrease muscle spasms, provide pain relief, and prevent recurrence of symptoms.

Biofeedback

Biofeedback teaches you how to lessen muscle tension through relaxation and visualization techniques. At first, sensors are placed on your jaw, and a machine shows the amount of tension in your muscles. Using relaxation and visualization techniques, you learn to reduce the amount of tension around your jaw while the machine provides instant feedback to guide you. Once you have mastered the technique, you can perform the relaxation and visualization techniques anywhere.

Improving posture

Two types of movement therapy can sometimes treat TMJ dysfunction: the Alexander technique and the Feldenkrais method.

The Alexander technique teaches you how to properly align your head, neck, and spine, and move your body. It can help relieve tension in your head and jaw muscles, possibly lessening the symptoms of TMJ dysfunction.

The Feldenkrais method teaches you to recognize bad posture habits and movements that cause your body to tense. It is a gentle therapy aimed at making you more aware of how your body moves, and helping you develop an inner awareness of your body. Feldenkrais is popular with dancers and musicians, who often perform repetitive motions.

Prognosis and Possible Complications

TMJ dysfunction is treated successfully in 75 percent of patients who follow a multifaceted treatment plan. In rare cases, prolonged teeth clenching or grinding, trauma, infection, or connective tissue disease may result in degenerative joint disease or arthritis. If you experience severe grinding, you may benefit from nighttime use of a bite guard worn inside your mouth.

Following Up

You may need to see your health care provider regularly to ensure your prescribed therapies are working for you.

Supporting Research

Challem J. TMJ pain may be aggravated by free radicals, relieved partly by anti-oxidants. The Nutr Reporter. 1998.

Crider AB, Glaros AG. A meta-analysis of EMG biofeedback treatment of temporomandibular disorders. J of Orofacial Pain. 1999;13(1):29-37.

Ernberg M, Hedenberg-Magnusson B, et al. Pai, allodynia and serum serotonin level in orofacial pain of muscular origin. J Orofacial Pain. 1999; Winter 13(1):56-62.

Ernst E. Acupuncture as a treatment for temporomandibular joint dysfunction. Arch Otolaryngol Head Neck Surg. 1999;125:269-272.

Jagger RG, Bates JF, Kopp S. Temporomandibular Joint Dysfunction. Oxford, England: Wright; 1994.

Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontol Scand. 1991;49:153-158.

List T, Helkimo M. Acupuncture and occlusal splint therapy in the treatment of craniomandibular disorders. Acta Odontol Scand. 1992;50:375-385.

List T, Helkimo M, Karlsson R. Pressure pain thresholds in patients with craniomandibular disorders before and after treatment with acupuncture and occlusal splint therapy: a controlled clinical study. J Orofac Pain. 1993;7:275-282.

Marbach JJ. Temporomandibular Pain and Dysfunction Syndrome. Rheum Dis Clin North Am. 1996;22(3).

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:111-114, 185-186, 187-189, 208-209, 237, 324-325, 329-330.

Rosen P, ed. Emergency Medicine: Concepts and Clinical Management. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998.

Rosted R. Practical recommendations for the use of acupuncture in the treatment of temporomandibular disorders based on the outcome of published controlled studies. Oral Dis. 2000;7:109-115.

Syrop, SB. Initial management of temporomandibular disorders. Dent Today. 2002 Aug;21(8):52-7.

Thie NM, Prasad NG, Major PW. Evaluation of glucosamine sulfate compared to ibuprofen for the treatment of temporomandibular joint osteoarthritis: a randomized double blind controlled 3 month clinical trial. J Rheumatol. 2001;28:1347-55.