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{{Short description|Disorders of the muscles and joints connecting the jaw to the skull}}
{{about|the syndrome with joint pain|the range of diseases affecting the joint|Temporomandibular joint pathology}}
{{Use dmy dates|date=October 2020}}
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<!-- Definition and symptoms -->
'''Temporomandibular joint dysfunction''' ('''TMD''', '''TMJD''') is an umbrella term covering [[pain]] and dysfunction of the [[muscles of mastication]] (the muscles that move the jaw) and the [[temporomandibular joint]]s (the joints which connect the [[Human mandible|mandible]] to the [[human skull|skull]]). The most important feature is pain, followed by restricted mandibular movement,<ref name="Mujakperuo 2010" /> and noises from the temporomandibular joints (TMJ) during jaw movement. Although TMD is not life-threatening, it can be detrimental to [[quality of life]];<ref name="Shi 2003">{{cite journal | vauthors = Shi Z, Guo C, Awad M | editor1-first = Zongdao | editor1-last = Shi | title = Hyaluronate for temporomandibular joint disorders | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD002970 | year = 2003 | pmid = 12535445 | doi = 10.1002/14651858.CD002970 }} {{Retracted
In this article, the term ''temporomandibular disorder'' is taken to mean any disorder that affects the temporomandibular joint, and ''temporomandibular joint dysfunction'' (here also abbreviated to TMD) is taken to mean symptomatic (e.g. pain, limitation of movement, clicking) dysfunction of the temporomandibular joint. However, there is no single, globally accepted term or definition<ref name="Medscape reference" /> concerning this topic.
<!-- Cause, diagnosis, and treatment -->
TMDs have a range of causes and often co-occur with a number of overlapping medical conditions, including headaches, fibromyalgia, back pain, and irritable bowel.<ref>{{
<!-- Epidemiology -->
The prevalence of TMD in the global population is 34%. It varies by continent: the highest rate is in South America at 47%, followed by Asia at 33%, Europe at 29%, and North America at 26%.<ref>{{Cite journal |last1=Zieliński |first1=Grzegorz |last2=Pająk-Zielińska |first2=Beata |last3=Ginszt |first3=Michał |date=2024-02-28 |title=A Meta-Analysis of the Global Prevalence of Temporomandibular Disorders |journal=Journal of Clinical Medicine |language=en |volume=13 |issue=5 |pages=1365 |doi=10.3390/jcm13051365 |doi-access=free |issn=2077-0383 |pmc=10931584 |pmid=38592227}}</ref> About 20% to 30% of the adult population are affected to some degree.<ref name="Guo 2009">{{cite journal | vauthors = Guo C, Shi Z, Revington P | s2cid = 19685120 | editor1-first = Chunlan | editor1-last = Guo | title = Arthrocentesis and lavage for treating temporomandibular joint disorders | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD004973 | date = October 2009 | pmid = 19821335 | doi = 10.1002/14651858.CD004973.pub2 }} {{Retracted
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* Neoplasia
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TMD is considered by some to be one of the 4 major symptom complexes in chronic orofacial pain, along with [[burning mouth syndrome]], [[atypical facial pain]] and [[atypical odontalgia]].<ref name="Aggarwal 2011">{{cite journal | vauthors = Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J | s2cid = 34127162 | editor1-first = Vishal R | editor1-last = Aggarwal | title = Psychosocial interventions for the management of chronic orofacial pain | journal = The Cochrane Database of Systematic Reviews | issue = 11 | pages = CD008456 | date = November 2011 | pmid = 22071849 | doi = 10.1002/14651858.CD008456.pub2 }} {{Retracted
===Definitions and terminology===
Frequently, TMD has been treated as a single [[syndrome]], but the prevailing modern view is that TMD is a cluster of related disorders with many common features.<ref name="Fernandez 2009" /> Indeed, some have suggested that, in the future, the term 'TMD' may be discarded as the different causes are fully identified and separated into different conditions.<ref name="Luther 2010" /> Sometimes, "temporomandibular joint dysfunction" is described as the most common form of temporomandibular disorder,<ref name="Al-Ani 2004">{{cite journal |vauthors = Al-Ani MZ, Davies SJ, Gray RJ, Sloan P, Glenny AM |s2cid = 28416906 |editor1-first = M Ziad |editor1-last = Al-Ani |title = Stabilisation splint therapy for temporomandibular pain dysfunction syndrome |journal = The Cochrane Database of Systematic Reviews |issue = 1 |pages = CD002778 |year = 2004 |pmid=14973990 |doi=10.1002/14651858.CD002778.pub2}} {{Retracted
The preferred terms in medical publications is to an extent influenced by geographic location. For example, in the [[United Kingdom]], the term 'pain dysfunction syndrome' is in common use.<ref name="Al-Ani 2004" /> In the United States, the term 'temporomandibular disorder' is generally favored. The American Academy of Orofacial Pain uses 'temporomandibular disorder', whilst the [[National Institute of Dental and Craniofacial Research]] uses 'temporomandibular joint disorder'.<ref name="Medscape reference" /> A more complete list of synonyms for this topic is extensive, with some being more commonly used than others. In addition to those already mentioned, examples include 'temporomandibular joint pain dysfunction syndrome', 'temporomandibular pain dysfunction syndrome', 'temporomandibular joint syndrome', 'temporomandibular dysfunction syndrome', 'temporomandibular dysfunction', 'temporomandibular disorder', 'temporomandibular syndrome', 'facial arthromyalgia', 'myofacial pain dysfunction syndrome', 'craniomandibular dysfunction' (CMD), 'myofacial pain dysfunction', 'masticatory myalgia', 'mandibular dysfunction', and 'Costen's syndrome'.
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Signs and symptoms of temporomandibular joint disorder vary in their presentation. The symptoms will usually involve more than one of the various components of the masticatory system, [[muscle]]s, [[nerves]], [[tendons]], [[ligaments]], [[bone]]s, [[connective tissue]], or the [[teeth]].<ref name="Okeson 2003">{{cite book |last=Okeson |first=Jeffrey P. | name-list-style = vanc |title=Management of temporomandibular disorders and occlusion |year=2003 |publisher=Mosby |location=St. Louis, Missouri |isbn=978-0-323-01477-9 |edition=5th |pages=191, 204, 233, 234, 227}}</ref>
The three classically described, cardinal signs and symptoms of TMD are:<ref name="Manfredini 2011">{{cite journal |
# Pain and tenderness on [[palpation]]<!-- <ref name="Al-Ani 2004" /> --> in the muscles of mastication,<!-- <ref name="Mujakperuo 2010" /> --> or of the joint itself (preauricular pain – pain felt just in front of the ear).<!-- <ref name="Mujakperuo 2010" /> --> Pain is the defining feature of TMD<!-- <ref name="Mujakperuo 2010" /> --> and is usually aggravated by manipulation or function,<ref name="Mujakperuo 2010" /> such as when chewing, clenching,<ref name="Neville 2001" /> or yawning,<!-- <ref name="Classification of Chronic Pain" /> --> and is often worse upon waking.<!-- <ref name="Classification of Chronic Pain" /> --> The character of the pain is usually dull or aching, poorly localized,<ref name="Cairns 2010" /> and intermittent, although it can sometimes be constant.<!-- <ref name="Classification of Chronic Pain" /> --> The pain is more usually unilateral (located on one side) rather than bilateral.<ref name="Classification of Chronic Pain" /> It is rarely severe.<ref name="Cawson 2002" />
TMJ dysfunction is commonly associated with symptoms affecting cervical spine dysfunction and altered head and cervical spine posture.<ref name=":11"/>
Other signs and symptoms have also been described, although these are less common and less significant than the cardinal signs and symptoms listed above. Examples include:
* Headache (possibly),<ref name="Al-Ani 2004" /> e.g. pain in the [[occiput|occipital region]] (the back of the head),<!-- <ref name="Neville 2001" /> --> or the forehead;<ref name="Neville 2001">{{cite book |vauthors=Neville BW, Damm DD, Allen CA, Bouquot JE |title=Oral & maxillofacial pathology |url=https://archive.org/details/oralmaxillofacia00nevi |url-access=limited |year=2002 |publisher=W.B. Saunders |location=Philadelphia |isbn=978-0-7216-9003-2 |pages=[https://archive.org/details/oralmaxillofacia00nevi/page/n87 75]–9 |edition=2nd}}</ref> or other types of facial pain including [[migraine]],<ref name="Okeson 2003" /> [[tension headache]],<ref name="Okeson 2003" /> or [[myofascial pain]].<ref name="Okeson 2003" />
* Pain elsewhere, such as the teeth<ref name="Neville 2001" /> or neck.<ref name="Edwab 2003" />
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[[Stress (psychological)|Emotional stress]] (anxiety, depression, anger) may increase pain by causing [[Autonomic nervous system|autonomic]], [[Viscus|visceral]] and skeletal activity and by reduced inhibition via the descending pathways of the [[limbic system]].<!-- <ref name="Aggarwal 2011" /> --> The interactions of these biological systems have been described as a vicious "anxiety-pain-tension" cycle which is thought to be frequently involved in TMD.<!-- <ref name="Aggarwal 2011" /> --> Put simply, stress and anxiety cause grinding of teeth and sustained muscular contraction in the face.<!-- <ref name="Aggarwal 2011" /> --> This produces pain which causes further anxiety which in turn causes prolonged muscular spasm at trigger points, [[vasoconstriction]], [[ischemia]] and release of pain mediators.<!-- <ref name="Aggarwal 2011" /> --> The pain discourages use of the masticatory system (a similar phenomenon in other chronic pain conditions is termed "fear avoidance" behavior), which leads to reduced muscle flexibility, tone, strength and endurance.<!-- <ref name="Aggarwal 2011" /> --> This manifests as limited mouth opening and a sensation that the teeth are not fitting properly.<ref name="Aggarwal 2011" />
Persons with TMD have a higher prevalence of psychological disorders than people without TMD.<ref name="Orlando 2007" /> People with TMD have been shown to have higher levels of anxiety, [[Depression (mood)|depression]], somatization and [[sleep deprivation]], and these could be considered important [[Risk factor (epidemiology)|risk factor]]s for the development of TMD.<ref name="Scully 2008" /><ref name="Orlando 2007" /> In the 6 months before the onset, 50–70% of people with TMD report experiencing stressful life events (e.g. involving work, money, health or relationship loss).<!-- <ref name="Scully 2008" /> --> It has been postulated that such events induce anxiety and cause increased jaw muscle activity.<!-- <ref name="Scully 2008" /> --> Muscular hyperactivity has also been shown in people with TMD whilst taking examinations or watching horror films.<ref name="Scully 2008" />
Others argue that a link between muscular hyperactivity and TMD has not been convincingly demonstrated, and that emotional distress may be more of a consequence of pain rather than a cause.<ref name="Glick 2003" />
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===Occlusal factors===
Occlusal factors as an etiologic factor in TMD is a controversial topic.<ref name="Scully 2008" /> Abnormalities of occlusion (problems with the bite) are often blamed for TMD but there is no evidence that these factors are involved.<ref name="Cawson 2002" /> Occlusal abnormalities are incredibly common, and most people with occlusal abnormalities do not have TMD.<ref name="Kerawala 2010" /> Although occlusal features may affect observed electrical activity in masticatory muscles,<ref name="Trovato 2009">{{cite journal | vauthors = Trovato F, Orlando B, Bosco M | title = Occlusal features and masticatory muscles activity. A review of electromyographic studies | journal = Stomatologija | volume = 11 | issue = 1 | pages = 26–31 | year = 2009 | pmid = 19423968 }}</ref> there are no [[statistical significance|statistically significant]] differences in the number of occlusal abnormalities in people with TMD and in people without TMD.<ref name="Scully 2008" /> There is also no evidence for a causal link between orthodontic treatment and TMD.<ref name="Scully 2008" /> The modern, mainstream view is that the vast majority of people with TMD, occlusal factors are not related.<ref name="Wassell 2008" /> Theories of occlusal factors in TMD are largely of historical interest. A causal relationship between occlusal factors and TMD was championed by Ramfjord in the 1960s.<ref name="Luther 2010">{{cite journal | vauthors = Luther F, Layton S, McDonald F | s2cid = 6920829 | title = Orthodontics for treating temporomandibular joint (TMJ) disorders | journal = The Cochrane Database of Systematic Reviews | issue = 7 | pages = CD006541 | date = July 2010 | pmid = 20614447 | doi = 10.1002/14651858.CD006541.pub2 | editor1-last = McDonald | editor1-first = Fraser }} {{Retracted
===Genetic factors===
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Generally, degenerative joint changes are associated with greater pain.
====='''Myofascial
Pain originating from the muscles of mastication as a result of abnormal muscular function or hyperactivity. The muscular pain is frequently, but not always, associated with daytime clenching or nocturnal bruxism.<ref>Contemporary Oral and Maxillofacial Surgery fifth edition; Hupp, ellis, and tucker. 2008</ref>
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Studies have shown that tomography of the TMJ provided supplementary information that supersedes what is obtainable from clinical examination alone.<ref>{{cite journal | vauthors = Wiese M, Wenzel A, Hintze H, Petersson A, Knutsson K, Bakke M, List T, Svensson P | display-authors = 6 | title = Osseous changes and condyle position in TMJ tomograms: impact of RDC/TMD clinical diagnoses on agreement between expected and actual findings | journal = Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics | volume = 106 | issue = 2 | pages = e52-63 | date = August 2008 | pmid = 18547834 | doi = 10.1016/j.tripleo.2008.03.021 }}</ref> However, the issues lies in the fact that it is impossible to determine whether certain patient groups would benefit more or less from a radiographic examination.<ref>{{cite journal | vauthors = Petersson A | title = What you can and cannot see in TMJ imaging--an overview related to the RDC/TMD diagnostic system | journal = Journal of Oral Rehabilitation | volume = 37 | issue = 10 | pages = 771–8 | date = October 2010 | pmid = 20492436 | doi = 10.1111/j.1365-2842.2010.02108.x }}</ref>
The main indications of [[CT scan|CT]] and CBCT examinations are to assess the bony components of the TMJ, specifically the location and extent of any abnormalities present.<ref name=":7">{{cite journal | vauthors = Ferreira LA, Grossmann E, Januzzi E, de Paula MV, Carvalho AC | title = Diagnosis of temporomandibular joint disorders: indication of imaging exams | journal = Brazilian Journal of Otorhinolaryngology | volume = 82 | issue = 3 | pages = 341–52 | date = May 2016 | pmid = 26832630 | doi = 10.1016/j.bjorl.2015.06.010 | pmc = 9444643 | doi-access = free }}</ref><ref name=":8">{{cite journal | vauthors = Klatkiewicz T, Gawriołek K, Pobudek Radzikowska M, Czajka-Jakubowska A | title = Ultrasonography in the Diagnosis of Temporomandibular Disorders: A Meta-Analysis | journal = Medical Science Monitor | volume = 24 | pages = 812–817 | date = February 2018 | pmid = 29420457 | pmc = 5813878 | doi = 10.12659/MSM.908810 }}</ref><ref>{{cite journal | vauthors = Al-Saleh MA, Alsufyani NA, Saltaji H, Jaremko JL, Major PW | title = MRI and CBCT image registration of temporomandibular joint: a systematic review | journal = Journal of
The introduction of cone beam computed tomography (CBCT) imaging allowed a lower radiation dose to patients, in comparison to conventional CT. Hintze et al. compared CBCT and CT techniques and their ability to detect morphological TMJ changes. No significant difference was concluded in terms of their diagnostic accuracy.<ref>{{cite journal | vauthors = Hintze H, Wiese M, Wenzel A | title = Cone beam CT and conventional tomography for the detection of morphological temporomandibular joint changes | journal = Dento Maxillo Facial Radiology | volume = 36 | issue = 4 | pages = 192–7 | date = May 2007 | pmid = 17536085 | doi = 10.1259/dmfr/25523853 }}</ref>
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===Medication===
Medication is the main method of managing pain in TMD, mostly because there is little if any evidence of the effectiveness of surgical or dental interventions.<!-- <ref name="Mujakperuo 2010" /> --> Many drugs have been used to treat TMD pain, such as [[analgesic]]s (pain killers), [[benzodiazepine]]s (e.g. [[clonazepam]], [[prazepam]], [[diazepam]]), [[anticonvulsant]]s (e.g. [[gabapentin]]), [[muscle relaxant]]s (e.g. [[cyclobenzaprine]]), and others. Analgesics that have been studied in TMD include [[non-steroidal anti-inflammatory drug]]s (e.g. [[piroxicam]], [[diclofenac]], [[naproxen]]
[[Topical medication|Topical]] [[methyl salicylate]] and topical [[capsaicin]] have also been used.<!-- <ref name="Mujakperuo 2010" /> -->
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In a subset of people with TMD who are not helped by either noninvasive and invasive treatments, long term use of [[opiate]] analgesics has been suggested, although these drugs carry a risk of [[drug dependence]] and other side effects.<ref name="Bouloux 2011">{{cite journal | vauthors = Bouloux GF | title = Use of opioids in long-term management of temporomandibular joint dysfunction | journal = Journal of Oral and Maxillofacial Surgery | volume = 69 | issue = 7 | pages = 1885–91 | date = July 2011 | pmid = 21419546 | doi = 10.1016/j.joms.2010.12.014 }}</ref> Examples include [[morphine]], [[fentanyl]], [[oxycodone]], [[tramadol]], [[hydrocodone]], and [[methadone]].<ref name="Bouloux 2011" />
Injections of [[local anesthetic]], sometimes combined with [[steroid]]s, into the muscles (e.g. the temoralis muscle or its tendon) are also sometimes used. Local anesthetics may provide temporary pain relief, and steroids inhibit pro-inflammatory [[cytokine]]s.<ref name="Hupp 2008" /> Steroids and other medications are sometimes injected directly into the joint (See [[#Intra-articular injections|Intra-articular injections]]). Platelet-rich fibrin injection, alone or associated with arthrocentesis, can be considered a very suitable.<ref name="Treatments for painful temporomandi">{{cite journal | vauthors = Al-Moraissi, EA et al.| title = Treatments for painful temporomandibular disc displacement with reduction: a network meta-analysis of randomized clinical trials | journal = International Journal of Oral and Maxillofacial Surgery| volume = 53 | issue = 1 | pages =
[[Botulinum toxin]] solution ("Botox") is sometimes used to treat TMD.<ref name="Schwartz 2002">{{cite journal | vauthors = Schwartz M, Freund B | s2cid = 37480726 | title = Treatment of temporomandibular disorders with botulinum toxin | journal = The Clinical Journal of Pain | volume = 18 | issue = 6 Suppl | pages = S198-203 | date = Nov–Dec 2002 | pmid = 12569969 | doi = 10.1097/00002508-200211001-00013 }}</ref> Injection of botox into the lateral pterygoid muscle has been investigated in multiple randomized control trials, and there is evidence that it is of benefit in TMD.<ref name="Persaud 2013">{{cite journal | vauthors = Persaud R, Garas G, Silva S, Stamatoglou C, Chatrath P, Patel K | title = An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions | journal = JRSM Short Reports | volume = 4 | issue = 2 | date = February 2013 | page = 10 | pmid = 23476731 | pmc = 3591685 | doi = 10.1177/2042533312472115 }}</ref> It is theorized that spasm of lateral pterygoid causes anterior disc displacement. Botulinum toxin causes temporary muscular paralysis by inhibiting [[acetylcholine]] release at the neuromuscular junction.<ref name="Glick 2003" /> The effects usually last for a period of months before they wear off. Complications include the creation of a "fixed" expression due to diffusion of the solution and subsequent involvement of the [[muscles of facial expression]],<ref name="Persaud 2013" /> which lasts until the effects of the botox wear off.
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Attempts in the last decade to develop [[Surgery|surgical treatment]]s based on [[MRI]] and [[Computed axial tomography|CAT]] scans now receive less attention. These techniques are reserved for the most difficult cases where other [[therapeutic modalities]] have failed. The [[American Society of Maxillofacial Surgeons]] recommends a conservative/non-surgical approach first. Only 20% of patients need to proceed to surgery.
Examples of surgical procedures that are used in TMD, some more commonly than others, include [[arthrocentesis]],<ref
===Alternative medicine===
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According to the most recent analyses of epidemiologic data using the RDC/TMD diagnostic criteria, of all TMD cases, group I (muscle disorders) accounts for 45.3%, group II (disc displacements) 41.1%, and group III (joint disorders) 30.1% (individuals may have diagnoses from more than one group).<ref name="Manfredini 2011" /> Using the RDC/TMD criteria, TMD has a prevalence in the general population of 9.7% for group I, 11.4% for group IIa, and 2.6% for group IIIa.<ref name="Manfredini 2011" />
The highest prevalence of TMD (regardless of type) is in South America at 47%, followed by Asia at 33%, Europe at 29%, and North America at 26%.<ref>{{Cite journal |last1=Zieliński |first1=Grzegorz |last2=Pająk-Zielińska |first2=Beata |last3=Ginszt |first3=Michał |date=2024-02-28 |title=A Meta-Analysis of the Global Prevalence of Temporomandibular Disorders |journal=Journal of Clinical Medicine |language=en |volume=13 |issue=5 |pages=1365 |doi=10.3390/jcm13051365 |doi-access=free |issn=2077-0383 |pmc=10931584 |pmid=38592227}}</ref>
==History==
Temporomandibular disorders were described as early as ancient Egypt.<ref name="Wright 2010">{{cite book|title=Manual of temporomandibular disorders|last=Wright|first=Edward F.| name-list-style = vanc |publisher=Wiley-Blackwell|year=2013|isbn=978-1-118-50269-3|edition=3rd|location=Ames, IA|pages=1–15}}</ref> An older name for the condition is "Costen's syndrome", eponymously referring to James B. Costen.<ref>{{WhoNamedIt|synd|4119|Costen's syndrome}}</ref><ref name="pmid9342976">{{cite journal | vauthors = Costen JB | s2cid = 30664556 | title = A syndrome of ear and sinus symptoms dependent upon disturbed function of the temporomandibular joint. 1934 | journal = The Annals of Otology, Rhinology, and Laryngology | volume = 106 | issue = 10 Pt 1 | pages = 805–19 | date = October 1997 | pmid = 9342976 | doi = 10.1177/000348949710601002 }}</ref> Costen was an [[otolaryngologist]],<ref name="Perry 1995" /> and although he was not the first physician to describe TMD, he wrote extensively on the topic, starting in 1934, and was the first to approach the disorder in an integrated and systematic way.<ref name="Michael 1997">{{cite journal | vauthors = Michael LA | s2cid = 57196481 | title = Jaws revisited: Costen's syndrome | journal = The Annals of Otology, Rhinology, and Laryngology | volume = 106 | issue = 10 Pt 1 | pages = 820–2 | date = October 1997 | pmid = 9342977 | doi = 10.1177/000348949710601003 }}</ref> Costen hypothesized that [[malocclusion]] caused TMD, and placed emphasis on ear symptoms, such as tinnitus, otalgia, impaired hearing, and even dizziness.<ref name="Michael 1997" /> Specifically, Costen believed that the cause of TMD was mandibular over-closure,<ref name="Perry 1995">{{cite journal | vauthors = Perry HT | title = Temporomandibular joint dysfunction: from Costen to the present | journal = Annals of the Academy of Medicine, Singapore | volume = 24 | issue = 1 | pages = 163–7 | date = January 1995 | pmid = 7605085 }}</ref> recommending a treatment revolving around building up the bite.<ref name="Perry 1995" /> The eponym "Costen syndrome" became commonly used shortly after his initial work,<ref name="Michael 1997" /> but in modern times it has been dropped, partially because occlusal factors are now thought to play little, if any, role in the development of TMD,<ref name="Medscape reference">{{cite web |title=Temporomandibular Disorders |website=Medscape |url=http://emedicine.medscape.com/article/1143410-overview#showall |publisher=WebMD |date=22 February 2017 |author=Joseph Rios |editor=Robert A. Egan |access-date=13 March 2019}}</ref> and also because ear problems are now thought to be less associated with TMD. Other historically important terms that were used for TMD include "TMJ disease" or "TMJ syndrome", which are now rarely used.<ref name="Medscape reference" />
On March 31, 2020, The [[American Dental Association]] officially recognized orofacial pain as a dental speciality.<ref>{{cite web | url=https://aaop.clubexpress.com/content.aspx?page_id=5&club_id=508439&item_id=53318 | title=Orofacial Pain is Now the 12th ADA-Recognized Dental Specialty - American Academy of Orofacial Pain }}</ref>
== References ==
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