Accurate Diagnosis of TMJ Pain and Dysfunction (Preview)
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Diagnostic Features
Temporomandibular Joint Pain and Dysfunction
Introduction
Temporomandibular Joint Disorders
Temporomandibular joint disorders are commonly seen in clinical practice. They are reported to be more common in women and have a peak age incidence of 20–40 years. Clinical presentations of temporomandibular joint disorders are characterized by acute or chronic pain and may include the following:
- Temporomandibular joint dysfunction
- Facial pain
- Ear pain, a feeling of ear fullness, and tinnitus
- Neck pain
- Orbital pain
- Dizziness
Temporomandibular Joint Dysfunction
Temporomandibular joint dysfunction is characterized by pain arising from an abnormal relationship between the temporomandibular joint (TMJ) articular disc and the adjacent articular surfaces, as well as the surrounding myofascial structures. The TMJ is an extremely important articulation necessary for mastication, swallowing, facial expression, and communication. This joint is classified as a ginglymoarthrodial joint allowing essentially a hinge-like movement (rotation) combined with a gliding motion (translation). On opening the mouth, the movement begins with rotation of the mandibular condyle in the glenoid fossa, followed by a forward translation of the condyles. The TMJ involves articulation between the mandibular condyle and the glenoid fossa of the temporal bone. These two osseous structures are separated by a fibrocartilagenous disc. The TMJ is strengthened by its joint capsule and several ligaments (the sphenomandibular, stylomandibular, pterygomandibular, malleolomandibular and collateral ligaments).
The muscles involved in the opening and closing of the mouth are the primary muscles of mastication, including the masseter, temporalis, and medial pterygoid muscles which elevate the mandible to close the mouth, and the lateral pterygoid muscle which assists in opening the mouth by guiding forward movement of the jaw. Innervation of the TMJ and its associated muscles involves branches of the third division of the trigeminal nerve.
The etiology of TMJ dysfunction is thought to be multifactorial including anatomical, pathophysiological, and psychosocial factors. Musculoskeletal dysfunction is the most common contributing factor to TMJ dysfunction. This could be due to the following:
- Joint trauma
- Muscle imbalance
- Poor head and neck posture
- Myofascial pain syndromes
- Internal joint derangement
- Degenerative joint disease
- Chronic bruxism (clenching or grinding the teeth)
- Dental malocclusion
- A physical manifestation of a psychological disorder (e.g., depression, anxiety, or post-traumatic stress disorder)
Differential Diagnosis of Orofacial Pain
Patients presenting with orofacial pain may be suffering from several conditions. The differential diagnosis includes the following:
- TMJ dysfunction
- Dental caries, abscess, or malocclusion
- Otitis media and otitis externa
- Upper cervical facet joint dysfunction
- Mastoiditis
- Migraine headache
- Cluster headache
- Tension-type headache
- Trigeminal neuralagia
- Post-herpetic neuralgia
- Giant cell arteritis (Temporal arteritis)
- Parotitis
- Mandibular fracture or dislocation
- Sinusitis
- Cancer of the jaw, head, or neck
History
- Preauricular pain that is usually described as deep and aching with sharp exacerbations on jaw movement
- Pain that may refer to the head and neck
- Pain that is aggravated by chewing, yawning, or talking for extended periods
- Joint clicking, popping, or snapping on jaw movement
- Limited jaw opening
- May have jaw-locking
- Headache
- May have associated otological symptoms (e.g., tinnitus, vertigo, earache, or hearing loss)
Physical Examination
- Abnormal mandibular movement
- Decreased TMJ range of motion (inability to fully open the mouth, typically 25 mm or less)
- Local tenderness over the joint and/or in the muscles of mastication
- Palpation may reveal a clicking or popping sensation with jaw movement
- Palpation may reveal grinding or crepitus with jaw movement
- Muscle tension or spasm
- Pain on jaw clenching due to dynamic loading
- May have evidence of tooth wear or malocclusion
- May have abnormal cervical posture
Diagnostic Imaging
The diagnosis of TMJ dysfunction is usually clinical. Plain radiography can help to rule out degenerative joint disease, fractures, dislocations, and bone pathology. Magnetic resonance imaging (MRI) is considered the gold standard for the investigation of TMJ disorders as it is able to assess soft tissue structures, articular disc displacement, and the presence of joint effusion.
Red Flags
The following are examples of red flags for patients presenting with orofacial pain:
- A history of significant injury
- Severe pain
- Unrelenting pain
- Nocturnal pain
- Unexplained weight loss
- Fever
- Deformity
- Trismus
- Significant swelling
- Unilateral hearing loss or a new onset of tinnitus
- Vestibular dysfunction
- Significant loss of range of motion
- Severe tenderness on palpation or severe pain with any examination procedure
If any red flags are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.
TMJ Palpation
When palpating the TMJ (e.g., by placing fingers in the patient’s ears while they open and close their mouth), if a crackling or grating sound or sensation is present, this suggests osteoarthritis. If a clicking sensation is present, this could indicate displacement of the intra-articular disc.
Innervation of the TMJ and Associated Muscles
Since innervation of the TMJ and its associated muscles involves branches of the third division of the trigeminal nerve, pain from mandibular pathology or the mandibular teeth can be referred to the preauricular area and misinterpreted as arising from TMJ dysfunction. On the other hand, pain arising from the TMJ may be perceived by the patient as an earache.
Myofascial Pain Syndrome Presenting as TMJ Pain
In patients presenting with TMJ pain, a complete clinical examination should include an evaluation for the presence of myofascial trigger points as either the primary cause of the pain or as a concomitant condition. The primary muscles to evaluate include the following:
- Medial Pterygoid: Pain primarily in the region of TMJ
- Lateral Pterygoid: Pain primarily in the region of TMJ and maxillary area sometimes resembling as “sinus pain”
- Masseter – Superficial Layer: Pain primarily in the lowewr jaw and zygomatic arch
- Masseter – Deep Layer: Pain primarily in the TMJ (trigger point palpated intraorally)
- Sternocleidomastoid – Clavicular Division: Pain primarily in the forehead (may refer to both sides), pain deep in the “ear” with/without feeling of lightheadedness and imbalance
- Sternocleidomastoid – Sternal Division: Pain primarily in the temporal region and deep behind the eye
Management
The suggested conservative therapy, home advice, and clinical tips in this section are based on published materials and the clinical experience of the authors of this course. This should not be interpreted as a prescriptive guide to the treatment of this or any other condition. The use of this content is subject to the “Disclaimer” found at the bottom of this web page.
Acute Phase
- Evaluation and Correction of Joint Dysfunction (if present) – If indicated, any management techniques that are applied should minimize excessive loading. We recommend using a handheld instrument-assisted procedure.
- Low Level Laser Therapy – Some patients benefit from the application of low level laser therapy over the involved TMJ to assist with pain reduction and healing.
- Myofascial Release – If any myofascial pain syndrome is present, treat the trigger points using myofascial release, particularly in the head and neck regions.
- Acupuncture – Some patients benefit from acupuncture treatment.
- Ice – Application of ice over the involved TMJ. The ice pack may be applied for 5 to 10 minutes as often as every hour.
Subacute and Rehabilitation Phase
- Correction of Joint Dysfunction (if present)
- Low Level Laser Therapy
- Acupuncture
- TMJ Isometric Exercises
- SCM and Temporalis Stretches
- Ice – Application of ice if the pain returns.
Acute Phase
- Avoid or minimize any aggravating activities (e.g., avoid eating foods that are difficult to chew, including chewing gum).
- Keep a good neck and back posture when sitting.
- Apply ice over the affected TMJ for about 5 to 10 minutes, several times a day. Ice can be applied as often as every hour.
Subacute and Rehabilitation Phase
- Continue to avoid or minimize any aggravating activities (e.g., avoid eating foods that are difficult to chew, including chewing gum).
- Perform the TMJ Isometric Exercises.
- Perform the SCM and Temporalis Stretches
- Stop these exercises if they worsen your symptoms and report it to your practitioner.
- Apply ice if your TMJ pain returns or is aggravated.
For Patients
Patient Information, Home Advice, and Exercise Prescription Sheets
- You may wish to give your patients the following downloadable and ready-to-use Patient Information, Home Advice and Exercise Prescription sheets. In our experience, patients who are well informed about their condition and the recommended management are more likely to achieve good outcomes, become loyal patients, and recommend their family and friends to seek treatment.
- To view, download, or print these sheets, simply click on the images below.
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Patient Exercise Sheets
- When appropriate, the patient should gradually begin doing their prescribed exercises at home. Always recommend warm-up activities before commencing specific exercises. Warm-up activities include simple limbering movements or prescribed strength exercises at light loads.
- If stretches are indicated, instruct your patients to perform them after they have completed their strengthening exercises.
- Always recommend warm-up activities before commencing specific exercises. Warm-up activities include simple limbering movements or prescribed strength exercises at light loads.
- Always instruct your patients to use caution when performing their exercises in order to avoid overloading, overstretching, or any undue pain.
- To view, download or print the Patient Exercise Sheet, simply click on the image below.
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A Problem-Solving Approach to History Taking and Physical Examination
The learning material in this unit is designed to improve your skills in history taking and physical examination. The material includes examples of clinical findings and their analysis using a problem-solving approach. As you read through the material and watch the videos, you are encouraged to identify whether all the required elements of history taking and physical examination have been adequately covered.
Taking the Patient’s History
Read the following case scenario to refresh and improve your clinical reasoning when taking the patient’s case history. When taking the patient’s history, the practitioner needs to obtain sufficient information to cover the following essential elements.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Your patient is a 32-year-old female teacher who presents with pain in the right side of her face which has been present for about two weeks. She points to the area in front of her right ear as the primary site of her pain. She first became aware of the pain within 24 hours following a dental consultation that required a prolonged procedure to repair a cracked tooth. She has since returned to the dentist who recommended taking painkillers and giving it time to resolve.
Analysis: Pain in the preauricular region can indicate several conditions, including:
- Temporomandibular joint dysfunction
- Myofascial pain syndromes (e.g., the medial and lateral pterygoids, masseter, and sternocleidomastoid muscles)
- Upper cervical facet joint dysfunction
- Dental caries, abscess, or malocclusion
- Otitis media and otitis externa
- Mastoiditis
- Trigeminal neuralgia
- Post-herpetic neuralgia
- Giant cell arteritis (Temporal arteritis)
- Parotitis
- Mandibular fracture or dislocation
- Cancer of the jaw, head, or neck
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
She describes the pain as a constant dull ache with sharp exacerbations brought on by jaw movement, particularly when chewing or yawning. She rates the dull ache as a 3 out of 10 and the sharp exacerbations as a 9 out of 10 in intensity. She has found that applying an ice pack over her right jaw temporarily relieves the dull ache. She took painkillers on the dentist’s advice which gave her temporary relief but has stopped taking them, preferring to get your assistance to resolve the problem instead. There has been no change in the intensity of her pain since the onset.
Analysis: Her description of pain aggravated by jaw movement strongly suggests the involvement of the TMJ, the muscles of mastication, or a dental problem. However, it may also indicate the presence of an external or middle ear infection. Pain relief with an ice pack may indicate an inflammatory process but may also be due to the analgesic effect, as is the case with the use of painkillers. That her pain intensity has not changed since the onset indicates that the problem is not resolving and warrants intervention.
Are there any associated symptoms?
She says that the sharp exacerbations of pain are accompanied by a clicking sensation in her right jaw when she chews food or yawns. The dull ache at her jaw sometimes spreads to the right side of her head, particularly after a full day of talking as a teacher. In addition, she complains of a mild right earache and thinks that the hearing in her right ear may be slightly diminished.
Analysis: An occasional jaw click that is not painful is common in the general population. However, when jaw movement causes pain accompanied by clicking, this could indicate TMJ dysfunction. The ache in the right side of her head is also consistent with TMJ dysfunction. However, it could also indicate the presence of myofascial pain syndrome and other conditions such as dental problems and ear infections. The perceived loss of hearing may indicate an ear infection, but this finding has also been reported in TMJ dysfunction.
Are there any red flags?
The patient is asked the following questions in order to identify any red flags that could indicate serious pathology. Even if the patient has already provided information in the case history that relates to these questions, it is recommended that they are readdressed to ensure a thorough exploration.
- Do your symptoms disappear even for a short time? “Yes. I am not aware of the pain when I first wake up in the morning.”
- Does the pain wake you up at night? “No.”
- Are you experiencing any dizziness or loss of balance? “No.”
- Have you recently had any fever, chills, or night sweats? “No.”
- Have you recently had an infection or other illness? “No.”
- Do you have a history of cancer, inflammatory arthritis, or fracture arising from minor trauma? “No”.
Analysis: None of the patient’s responses raise a red flag.
Differential Diagnosis
Based on the available history, the list of possible causes of the patient’s complaint includes:
- Temporomandibular joint dysfunction
- Myofascial pain syndromes (e.g., the medial and lateral pterygoids, masseter, and sternocleidomastoid muscles)
- Upper cervical facet joint dysfunction
- Dental malocclusion
- Otitis media and otitis externa
- Mastoiditis
- Trigeminal neuralgia
- Parotitis
Reflection Points
Please stop and take a moment to consider whether the main requirements of an adequate and relevant patient history taking have been fulfilled. Are there any additional questions you would have asked and, if so, why?
Before the physical examination findings are presented below, please reflect on what physical examination procedures you would perform to adequately evaluate this patient.
Performing Physical Examination
In the sections below, you are provided with examples of physical examination findings for this patient. The material presents a systematic approach to performing a focused and relevant physical examination in order to narrow down the possible causes for the patient’s complaint. The material also provides ongoing clinical reasoning and analysis of the findings. As you read the following material, you are encouraged to identify whether the essential elements of physical examination have been adequately covered.
Vital Signs
Her vital signs are within normal limits.
Inspection
Inspection of the right preauricular area reveals no evidence of swelling, redness, or deformity. Inspection of the right ear, including an otoscopic examination, is found to be normal. Inspection of her head and neck posture is also normal.
Analysis: The absence of abnormal findings on inspection of the preauricular area helps to rule out fracture, dislocation, inflammation, or infection. The normal ear examination helps to rule out otitis media and otitis externa. The normal head and neck posture helps to rule out any cervical postural aberrations contributing to her condition.
Range of Motion
The TMJ Active Movement Assessment is performed and reveals a reduction in jaw opening with a measurement of only 25 mm. It also reveals pain in the right TMJ on full opening, with the jaw deviating to the right. When asked to move her jaw from side to side, limited movement to the left side is noted, with the patient complaining of pain in the right TMJ. Assessment of the cervical active and passive ranges of motion is found to be normal.
Analysis: The results of the TMJ Active Movement Assessment indicate TMJ dysfunction caused by limited mandibular opening due to either:
- Hypertonicity or imbalance in masticatory muscles
- Displacement of the meniscus in the TMJ resulting in interference with the normal forward movement of the mandibular condyle
- TMJ pathology (e.g., arthritis or bone pathology)
The absence of findings on assessment of the cervical ranges of motions helps to rule out cervical spine involvement. Please watch the video below if you wish to see how the TMJ Active Movement Assessment is performed.
Resisted Jaw Movement Assessment
The Resisted Jaw Movement Assessment is performed and reveals an aggravation of the patient’s pain on resisted jaw closure and resisted deviation to the left.
Analysis: These findings are further evidence of TMJ dysfunction either due to an intraarticular disorder or the involvement of the muscles of mastication. Please watch the video below if you wish to see how the Resisted Jaw Movement Assessment is performed.
Palpation
The right TMJ is tender on palpation. While palpating, jaw opening and closing reveal a clicking sensation accompanied by pain. In addition, it is noted that the right mandibular condyle is not sliding forward adequately. Muscle palpation reveals tenderness in the right medial and lateral pterygoid, temporalis, and masseter muscles. No nodules or pain referral to the TMJ is found on examination of the masseter and the SCM muscles. Neither the mastoid nor the parotid glands are tender on palpation. A functional examination of the cervical vertebral motion segments is found to be normal.
Analysis: The tenderness, the clicking sensation, and the inadequate forward movement of the right mandibular condyle on TMJ palpation provide strong evidence for TMJ dysfunction. In addition, the tenderness on palpation of the muscles of mastication also supports this diagnosis. The absence of nodules and pain referral on examination of the masseter and SCM helps to rule out myofascial pain syndrome involving these muscles. A normal functional examination of the cervical vertebral motion segments helps to rule out their involvement. The examination findings have also helped to rule out mastoiditis or parotitis. Please watch the video below if you wish to see how a palpation examination of the TMJ and the muscles of mastication can be performed.
Neurological Examination
A Screening Examination of the Cranial Nerves reveals no abnormalities. Notably, there are no sensory disturbances in the trigeminal nerve distribution.
Analysis: The absence of abnormal findings is reassuring as it helps to rule out neurological causes for the patient’s complaint. Please watch the video below if you wish to see how a Screening Examination of the Cranial Nerves can be performed.
Reflection Point
Given the patient’s history and examination findings up until this point, please stop and take a moment to consider which special tests should be performed to further evaluate this patient.
Special Tests
The Weber and Rinne tests are performed and are found to be normal.
Analysis: The normal results of these tests help to rule out hearing loss. Please watch the videos below if you wish to see how these tests are performed.
The Axial Cervical Compression test is performed and is found to be negative, with no localised upper neck pain or referral to the preauricular region.
Analysis: Involvement of the cervical facet joints can lead to localized neck pain or cause pain referral to the skull. As shown below, the C1-C2 facet joints may cause a pain referral to the preauricular, occipital, and orbital regions, as well as the vertex.
The negative result of the Axial Cervical Compression test for this patient suggests that there is no involvement of the upper cervical facet joints. Please watch the video below if you wish to see how the Axial Cervical Compression test is performed.
Reflection Point
Please stop and take a moment to consider whether all the elements of an adequate and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed and, if so, why?
Diagnosis
Right TMJ dysfunction.
References and Suggested Further Readings:
Pavia S. et al. Chiropractic Treatment of Temporomandibular Dysfunction: A Retrospective Case Series. J Chiropr Med. 2015 Dec;14(4):279-84.
Lomas J. et al. Temporomandibular dysfunction. AJGP. Volume 47, Issue 4, April 2018.
Travell J. Temporomandibular joint pain referred from muscles of the head and neck. J Pros Dent. 1960;10:745.
Shanavas M. et al. Transcutaneous electrical nerve stimulation therapy: An adjuvant pain controlling modality in TMD patients – A clinical study. Dent Res J (Isfahan). 2014 Nov;11(6):676-9.
Ba S. et al. Ultrasound is Effective to Treat Temporomandibular Joint Disorder. J Pain Res. 2021 Jun 10;14:1667-1673.
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Copyright © Educom Pty Ltd: All material on this website (including the text, graphics, videos and downloadable files) are owned by or licensed to Educom Pty Ltd and is subject to copyright and other intellectual property rights under international conventions.