When patients present with pain in or around the ear, popping or clicking in front of the ear, or jaw pain, this is usually the first question they ask.

They have likely been told they have “TMJ” by another dentist or other medical professionals. The short answer to this question, unless the patient is an earthworm, is “yes.” In fact, all vertebrate animals, including humans, have two TMJs.

The temporomandibular joint is the joint that allows the lower jaw to move in order to chew, swallow, speak, yawn, kiss, and help keep the airway open. What these patients – and even other professionals who have suggested the term to them – mean is “Do I have a temporomandibular disorder?”

History: Identify the etiology

Following the evidence-based biopsychosocial model of diagnosis and care that has been embraced by orofacial pain specialists, a thorough diagnosis of TMD – as with other orofacial pain conditions – begins with a thorough medical history review.

The examination should include a careful review of the patient's medical and dental history, including medications and associated dosages along with the time of day taken, previous treatment for the chief complaint, specific locations of the pain or areas of concern, previous surgeries, and date of onset of the chief complaint, as well as any similar previous episodes.

Any clinical records and imaging from previous providers regarding the chief complaint should also be reviewed. Validated screening tools for sleep disorders and psychological concerns should also be completed by the patient and reviewed as part of the diagnostic records. (Examples include the Epworth Sleepiness Scale, STOP-BANG Questionnaire, the GAD-7 that screens for general anxiety disorder, and PHQ-4 or PHQ-9 that screen for depression risk). Appropriate referrals should be made based on the responses to any screening questionnaires that are completed.

Examination: Knowledge is power

3D areas of a face and jaw on a black background
This patient was referred for new denture therapy by her primary care physician because she was having “TMJ” that was believed to be due to poorly fitting removable dentures. The true source of this patient's pain was a closed fracture of the subcondylar process.

The clinical examination technique for TMDs is taught in dental schools at a basic level and addressed in greater depth in Spear’s “Occlusion in Clinical Practice” workshop and in the “TMD Examination and Diagnosis for the Dental Team” pathway on Spear Online. Additionally, learners can attend the Spear special-focus workshops “TMD – Joints, Muscles, Occlusion and Posture” and “TMD II – Diagnostic, Therapeutic and Restorative Considerations,” and more detailed examination techniques are also taught in residency programs in specialty fields like orofacial pain.

An evidence-based examination protocol that is reproducible, relatively easy to calibrate, and rapidly implemented in practice, is outlined in the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Regardless of the style of the examination utilized, the TMJ examination should at a minimum include palpation of the muscles of the jaw and head, assessment of the mandibular range of motion, and palpation of the TMJs.

When performed properly, clinical examinations are reliable for diagnosing many TMJ disorders even without imaging.1 Appropriate imaging – whether it be panoramic radiography, cone beam computed tomography, computed tomography, magnetic resonance imaging, or a combination of these modalities – should be used to confirm or rule out clinical diagnoses and when the anticipated information gained from the imaging modality is likely to affect the treatment plan for the given diagnosis or diagnoses.

Diagnosis: Key to treatment planning

TMD is an extremely broad term and includes disorders of the muscles of mastication, ligaments of the stomatognathic system, and osseous structures of the temporomandibular joints.

Some clinicians might even include neurological conditions in this group, but those conditions are better described as orofacial pain. TMD includes temporomandibular joint disorders (TMJD) and muscle-related disorders like myofascial pain, local myalgia, myospasm, etc. If only the osseous structures of the joint and/or capsule of the joint are involved, the more appropriate term would be TMJD if the condition is strictly related a disorder of the bone of the joints or the capsule of the joint itself.

The diagnosis of temporomandibular disorders is complex and requires a thorough examination supported by imaging of various modalities (panoramic radiograph, cone-beam computed tomography, magnetic resonance imaging, etc.).

TMD is a broad term that is not really a diagnosis that leads to the most appropriate treatment. In fact, disorders of TMJs can be of different origins: ligament injuries, problems with the bone, inflammation of the blood vessels and nerves surrounding the temporomandibular joints, and muscle problems that may refer pain to the temporomandibular joint and surrounding areas.

The actual diagnoses of these conditions change names and medical billing codes (Table 1) from time to time, but as of the time of this publication there are more than 40 diagnoses that fall under the broad “TMD” term and each requires specific approaches to treatment. Others do not require treatment at all.

Muscular Myalgia (M79.1)
Myofascial Pain with Referral (M79.1)
Myofascial Pain with Spreading (M79.1)
Centrally Mediate Myalgia (M78.1)
Protective Co-Contraction (N/A)
Fibromyalgia (M79.7)
Oromandibular Distonia (G24)
Oromandibular Dyskinesia (R27.0)
Spasm (M62.838)
Tendonitis (M67.90)
Non-infective Myositis (M60.9)
Infective Myositis ((M60.009)
Contracture (M62.40)
Hypertrophy (M62.9)
Neurovascular Arthritis (M26.62)
TMD Headache (G44.89)
Skeletal diseases and anomalies Arthralgia (M26.62)
Disc Displacement with Reduction (M26.63)
Disc Displacement with Reduction with Intermittent Lock (M26.63)
Disc Displacement without Reduction with Limited Opening (M26.63)
Disc Displacement without Reduction without Limited Opening (M26.63)
Fibrous Ankylosis (M26.61)
Bony Ankylosis (M26.61)
Adhesions (M26.61)
Subluxation (S03.0XXA)
Luxation (S03.0XXA)
Degenerative Joint Disease (M19.91)
Condylysis/ Idiopathic Condylar Degeneration (M26.69)
Osteochondritis Dissecans (M93.20)
Osteonecrosis (M87.08)
Systemic Arthritides (M06.9)
Synovial Chondromatosis (D48.0)
Closed Fracture of the Condylar Process (S02.61XA)
Closed fracture of the Subcondylar Process (S02.62XA)
Open Fractured of the Condylar Process (S02.61XB)
Open Fracture of the Subcondylar Process (S02.62XB)
Condylar Aplasia (Q67.4)
Condylar Hypoplasia (M27.8)
Mandibular Hyperplasia (M27.8)
Coronoid Hyperplasia (M27.8)
Benign Neoplasm of the TMJ (D16.5)
Malignant Neoplasm of the TMJ (C41.1)

Table 1: Temporomandibular disorders ICD-10 codes.2

Aside from the variety of diagnoses included under the TMD umbrella, most TMD patients have more than one diagnosis. For example, a patient who has arthralgia may also have arthritis, disc displacement without reduction, myalgia, and myofascial pain with spreading or any other combination.

Treat with intention

Each condition requires treatment targeted to that specific diagnosis. Sometimes a therapeutic regimen can be designed to treat many of the conditions simultaneously. Currently prevailing research studies do not support first-line treatment of most TMDs with irreversible treatment like bite adjustments, orthodontic tooth movement, or surgical intervention.

Self-care regimens under clinician guidance, physical self-regulation exercises, cognitive behavioral therapy utilizing mental health professionals, physical therapy, massotherapy, and occlusal orthotic therapy (bite splints) designed toward specific treatment outcomes have been proven to be effective strategies in most cases. Occasionally, medications including low-dose tricyclic antidepressants, serotonin/norepinephrine reuptake inhibitors, anti-inflammatory medications, and sometimes muscle relaxants, are used to obtain maximal therapeutic results.

Nutritional counseling – including appropriate supplementation of vitamin D, vitamin B complex, magnesium, and calcium – is often beneficial, as well. In fact, it has been suggested and reported by many patients suffering from chronic TMD pain that cannabinoids like CBD have provided significant relief.

Bite splints, mouthguards, nightguards, and occlusal orthotic appliances may or may not be synonymous terms, depending on the knowledge and expertise of the clinician prescribing them. Just because a patient had ineffective therapy with one type of bite splint made by one dentist, which may have been made to actively the position the mandible into a particular position or might even have had no specific goal in mind but simply was the dentist’s “go-to” splint design, or even if multiple providers have prescribed a variety of different types of appliances for “TMD,” an appropriately trained clinician who independently evaluates the case and designs a treatment plan specifically tailored for that particular patient's clinical diagnosis may likely have much greater success.

The main goal of bite splint therapy in TMD therapy is to enable the body to adapt to a degenerative process or heal from injury. As I commonly tell my patients, bite splints may all look the same, but they are never similar.

1 - In the last 30 days, how long did any pain last in your jaw or temple area on either side?
a) No pain
b) Pain comes and goes
c) Pain is always present
2 - In the last 30 days, have you had pain or stiffness in your jaw on wakening?
3 - In the last 30 days, did the following activities change any pain (that is, make it better or make it worse) in your jaw or temple area on either side?
a) Chewing hard or tough food?
b) Opening your mouth or moving your jaw forward or to the side?
c) Jaw habits such as holding your teeth together, clenching, grinding or chewing gum?
d) Other jaw activities such as talking, kissing, or yawning?

Table 2: The TMD Pain Screener2 can be used to readily and predictably identify if a patient has a TMD. Positive responses to two or more of the questions reveal that an in-depth examination for TMD diagnosis is indicated.

Kevin D. Huff, D.D.S., M.A.G.D., is a diplomate of the American Board of Orofacial Pain. He is a member of Spear Visiting Faculty, a moderator on the Spear Talk online forum and a contributor to Spear Digest.

References

1) American Academy of Orofacial Pain. de Leeuw R, Klasser GD (editors). Orofacial Pain Guidelines for Assessment, Diagnosis, and Management. 6th edition. 2018. Quintessence Publishing Co., Inc. 153-189.

2) Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. Journal of Oral & Facial Pain and Headache 2014;28(1):6-27 https://ubwp.buffalo.edu/rdc-tmdinternational/wp-content/uploads/sites/58/2017/01/DC-TMD-Protocol-2013_06_02.pdf. Accessed August 1, 2019.

3) Gonzalez YM, Schiffman E, Gordon G, Seago B, Truelove EL, Slade G, Ohrbach R. Development of a brief and effective temporomandibular disorder pain screening questionnaire: reliability and validity. JADA 142:1183-1191, 2011.


Comments

Commenter's Profile Image James C.
October 21st, 2019
Excellent outline. I am always interested in the affects of pharmaceuticals increasing parafunctional activity. That would be a helpful discussion.