Temporomandibular Joint Disorder (TMD) describes a complex group of muscle and joint disorders affecting the TMJ, leading to pain, dysfunction and eventually degeneration. Most causes of TMD can be divided into either muscular or arthrogenous (joint).
TMD of muscle origin is more common (1) and may arise from: muscular hypertonicity, trigger points, fascial restrictions and/or functional muscle imbalance of the muscles used for chewing. One of the most commonly involved muscles is the masseter. Other recognized triggers for muscular TMD include: bruxism, clenching, neck joint dysfunction (2), postural syndromes, especially a forward head posture (3,4), and trauma (5). TMD symptoms may occur in up to one third of those patients involved in a whiplash injury (6). Psychosocial disturbances including stress and depression, are another widely recognized co-morbidity for TMD.
I heard jaw problems are because of having my teeth pulled?
Studies vary on the relationship of premolar extraction (tooth pulling) to the development of TMD, but recent evidence shows that tooth pulling is not related to jaw dysfunciton. (7).
How common is TMD?
Estimates for the incidence of TMD vary between 4-25% (8,9). Up to 3% of Americans seek treatment for TMD each year (21). At presentation, most patients are 20-50 years old and prevalence is 2-3 times higher in females.
What are the symptoms of TMD?
Typical symptoms include: clicking, restricted opening, transient locking and pain. Symptoms may be worsened by chewing. TMD pain is generally described as an “ache” just in front of the ear canal but may refer to other areas of the face, head, neck and shoulders (6). TMD patients often suffer concurrently from headaches, suggesting a common link arising from the upper cervical spine (10).
Do I need imaging for TMD?
Often times, a trial of care of 4-6 weeks including treatment will proceed any imaging. If imaging is needed, CT is the imaging of choice (over 4 times better than plain films) for identifying TMJ osteoarthritis. The reliability of MRI is also excellent for detecting disc displacements and effusion (12). Diagnostic ultrasound is a non-invasive imaging option that can easily identify TMJ disc displacement.
Treatment options for TMD:
Management should be conservative and simple, focusing on three main points: manual therapies, exercise and avoidance of aggravating activities.
Manual therapy is an effective treatment for TMD. (30) In fact, non-surgical intervention for myogenous TMD has been shown to be as effective as any surgical intervention (13). TMJ non-thrust mobilization is often indicated (10).Manipulation of the cerviocranial, cervical and thoracic spine may be necessary (16). Chiropractic cervical spine manipulation has been shown to increase maximal bite force (31).
Exercises to improve posture and TMJ function have been shown to be beneficial (10,17,18). Stretching exercises should address tightness in the masseter, SCM, levator and suboccipitals. Patient’s should also work on chin retractions, deep neck flexion and chin depression exercises.
Patients should avoid aggravating activities like chewing gum or eating “rubbery” type foods. Patients should also limit unnecessary talking (18,19). Glucosamine and chondroitin sulfate have shown success in managing TMD (34). Supplementation with bromelin or MSM may also be beneficial. A custom fitted mouth guard can help prevent clenching and promote relaxation of muscles (20). Patients with symptoms at night should avoid stressful activity before bedtime and be aware of their sleeping position.
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