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Diagnosis & Management of Temporomandibular Joint Disorders

INTRODUCTION
          Temporomandibular disorders (TMD) or Jaw joint/ TMJ disorders 
are one of the most common causes of facial pain after odontogenic origin (dental causes).
The temporomandibular disorders (TMD) are of multifactorial etiology and characterized by multiplicity of clinical signs and symptoms, making its diagnosis and management very difficult for the clinician.
TMD should be considered in the differential diagnosis of headache, neck pain, back pain, shoulder pain, pain around eyes and forehead, blurring of vision, ear pain, fullness in the ears, tinnitus (ringing in the ears), vertigo, dizziness, psychological problems, lack of concentration,anxiety, nausea, vomiting, and oro-facial pain in the absence of specific attributable organic cause.
Scientific evidence shows that non-invasive methods are preferred in the management of TMD. These include occlusal, behavioural  physical and pharmacological treatment.
Practitioners of medicine and dentistry have the responsibility of diagnosing and managing people with TMD or refer them to an appropriate health care professional based on the nature and etiology of the problem. 

Uniqueness of the TM Joint 
  • The TMJs are 2 joints, formed by 3 bones and their functions are interdependent. 
  • The articulating surfaces of the TMJ are covered by a fibrous connective tissue; this avascular and non-innervated structure has a greater capacity to resist degenerative change and regenerate itself than the hyaline cartilage of other synovial joints.
  • They are synovial joints with both rotatory and translatory movements possible.
  • The articular disc completely divides the joint space into separate upper and lower joint compartments.
  • The functions of the joints are not only influenced by the muscles and ligaments, but also by the teeth and their alignment.

Signs and Symptoms of Temporo mandibular joint disorders / Jaw Joint problems
  • Soreness of Muscles of mastication
  • Attrition of teeth and sensitivity
  • Hypermobility of teeth
  • Pain in the joints
  • Clicking in the joints
  • Crepitation in the joints
  • Difficulty in opening of mouth
  • Open lock of the mandible
Treatment
 The signs and symptoms of TMD improve for most of the patients over time with or without treatment. As much as 50 percent of the patients improve from TMD symptoms in one year and almost 85 percent improve completely in three years. Interventions that change the anatomy of the joint, invade the integrity of the joint space, or manipulate the jaw have the potential to cause harm and have not been shown to improve symptoms. Therefore, self-care and noninvasive treatments are good options and should be attempted before invasive or permanent therapies, such as orthodontics or surgery, are recommended.  

SELF-CARE
There is little evidence to suggest that any TMJ disorder treatment modality is superior to any other, although it is generally accepted that self-care and behavioral interventions should be encouraged for all patients, regardless of which therapies are considered. Providing a few simple exercises, behavioral instructions, and reassurance are important steps when treating the average patient with new or intermittent symptoms. 

NONINVASIVE THERAPY

 Many noninvasive therapies are commonly used for the treatment of TMJ disorders. The disciplines of medicine, dentistry (occlusal splint therapy, replacement of missing teeth, correcting malocclusion), physical therapy, and psychology can provide effective treatment in different clinical situations.
Pharmacotherapy
The indicated classes of pharmacologic agents include analgesics, anti-inflammatory agents, corticosteroids, anxiolytics, muscle relaxants and antidepressants. Non-opiate analgesics are effective for mild to moderate acute pain associated with TMD, and opioid narcotics are considered for short-term use in only controlling acute severe pain. Additionally, tricyclic antidepressants appear to be effective in the control of chronic orofacial pain of non-inflammatory origin, independent of their effects on mood, with daily doses smaller than those typically used in the treatment of depression. As most of the patients with TMJ disorders improve with or without treatment, these conservative therapies should be encouraged before invasive treatments are considered.
Alternative therapies Acupressure, Acupuncture, Hypnosis, Massage
Dental procedures  occlusal splint therapy, replacement of missing teeth, correcting malocclusion using braces, Occlusal adjustments
Medical interventions Intra-articular corticosteroid or anesthetic injection, Myofascial trigger-point injection, Pharmacologic treatment, Acetaminophen, Anxiolytics, Benzodiazepines, Muscle relaxants   Nonsteroidal anti-inflammatory drugs, .Tricyclic antidepressants
Physical therapy modalities Biofeedback Iontophoresis Superficial or deep heat Therapeutic exercise   Lateral jaw movement   Protrusive jaw movement   Resisted closing   Resisted opening   Tongue-up exercise Transcutaneous electrical nerve stimulation
Psychological interventions Cognitive behavior therapy, Relaxation techniques, Stress management
  Surgical treatment    Surgery is indicated only in specific articular disorders, usually in cases that do not respond to conservative treatment, and when the patient’s quality of life has been significantly affected.Surgical management may vary from closed surgical procedures, such as arthrocentesis and arthroscopy, to more complex open joint operations, such as arthrotomy, disk repositioning, diskectomy and condylotomy.

Conclusion Medical and dental practitioners should consider temporomandibular Joint disorders as a possible cause in the diagnosis of oro-facial pain including headaches, shoulder and neck pain, vertigo and associated pain, blurring of vision, disorders of hearing, nausea, vomiting, and disturbances in concentration, in the absence of any specific, attributable or organic cause.
While orofacial pain and headache secondary to jaw muscle function and dental structures ideally be managed by dentists, pain in the head and neck region unrelated to it should be should be referred to an appropriate medical care specialists for management. 
Keywords – TMD, Temporomandibular disorders, headache, facial pain, diagnosis

Review article by
Dr.S.Venkateswaran

Consultant orthodontist -Venkat Dental Center
Professor and Head, Department of Orthodontics
Chettinad Dental College and Research Institute
Chennai
Ph 044-24746073, 24746078, 9444845443, 9003230250

Doctor Dr. Venkateswaran Sundaram, 2013081923:33:58



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