ISSUE 145: Special Section

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Temporomandibular Joint Dysfunction

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LEXINGTON Oral and maxillofacial surgery is an exciting field that encompasses complex clinical problems ranging from the removal of teeth and placement of dental implants, to repair and reconstruction of difficult traumatic facial injuries. The variety of clinical problems affecting the jaws and face is the primary reason I entered my chosen specialty, and what keeps me enthusiastic. The Division of Oral and Maxillofacial Surgery and The University of Kentucky offer specialty service in the areas of trauma and reconstruction, orthognathic surgery, and pathology of the face and jaw. One of my areas of interest, the treatment of patients with temporomandibular joint dysfunction, will likely be relevant to many providers.

Facial pain and temporomandibular joint (TMJ) dysfunction are clinical problems seen with relative frequency in our population. Benign TMJ pops or clicks affect up to 30 percent of the population; only five percent of those people will have a problem that requires surgical intervention. The typical patient is female and from 30 to 50 years of age. Symptoms can include pre-auricular pain, joint sounds, limited mouth opening, headaches, ear pain, and pain on chewing.

The type of treatment provided for the facial pain patient depends first on an accurate diagnosis. Facial pain can be associated with inflammatory conditions of the TMJ, myofascial pain, and neuropathic pain. Etiologies can include trauma, parafunctional habits (e.g., night-time grinding, nail biting, mandibular posturing), malocclusion (abnormal jaw relationship), muscle tension (tension headaches), osteoarthritis, rheumatoid arthritis, and idiopathic conditions. Degenerative joint disease can be progressive, passing through five stages, ending in variable chronic pain, TMJ crepitation, and painful function. Our evaluation of these patients includes a history and physical exam, a screening radiograph of the jaws (panoramic radiograph), and usually an MRI of the joints in open and closed mouth views.

The interaction between myofascial pain and joint dysfunction, as in other areas, can sometimes be a diagnostic dilemma, and often patients have elements of joint disease as well as muscular pain. Most frequently, trials of non-surgical therapeutic modalities are attempted prior to surgical intervention, which can include counseling, medications, trigger point injections, splint therapy, or physical therapy. At The University of Kentucky, we are fortunate to have an active and well-known facial pain group with which we collaborate, particularly on patients who have challenging diagnoses or are in need of extensive non-surgical therapy.

Surgical intervention may be indicated when non-surgical therapies have failed to result in significant improvement and when facial pain is associated with significant dysfunction in the joint (disc or ligamentous injury or displacement), a chronically dislocating joint, a neoplasm, a significant malocclusion, or neuropathic pain associated with a peripheral nerve injury. Surgical therapies may include joint lavage, arthroscopic surgery, or open disc repair. In more severe cases, such as advanced arthritic disease or post-traumatic joint ankylosis, a total joint replacement may be required.

With correct diagnosis and treatment, the majority of patients can have good function with minimal pain. There are unfortunate patients who will require chronic pain management. In these situations we work with patients to find appropriate pain specialists for referral.