Temporomandibular disorders (TMD) is the name given to several problems with jaw
movement and pain in and around the
jaw joints.
You may also hear TMD called TMJ or
TM problems.
The jaw joints, or
temporomandibular (TM) joints, connect the lower
jawbone (mandible) to the skull. These flexible joints are used more than any
other joint in the body. They allow the jaw to open and close for talking,
chewing, swallowing, yawning, and other movements.
Many people
have problems with jaw movement and pain in and around the jaw joints at some
time during their lives. These joint and muscle problems are complex. So
finding the right diagnosis and treatment of TMD may take some
time.
What are the symptoms?
Temporomandibular disorders (TMD) can affect the
jaw and jaw joint as well as muscles in the face, shoulder, head, and neck.
Common symptoms include joint pain, muscle pain, headaches, joint sounds,
trouble with fully opening the mouth, and jaw locking.
In most
cases, symptoms of TMD are mild and don't last long. They tend to come and go without
getting worse and usually go away without a doctor's care.
Some
people who have TMD develop long-lasting (chronic) symptoms. Chronic pain or difficulty moving the jaw may affect talking, eating, and
swallowing. This may affect a person's overall sense of well-being.
What causes temporomandibular disorders?
The most common cause of
TMD symptoms is muscle tension, often triggered by stress. When you are
under stress, you may be in the habit of clenching or grinding your teeth.
These habits can tire the jaw muscles and lead to a cycle of muscle spasm,
tissue damage, pain, sore muscles, and more spasm.
TMD
can start when there is a problem with the joint itself, such as:
An injury to the joint or the tissues around
it.
Problems with how the joint is shaped.
Joint
diseases, such as
osteoarthritis or
rheumatoid arthritis.
The articular disc
that cushions the joint shifts out of place.
How is a temporomandibular disorder diagnosed?
Although there is
no one way to identify a TMD, your doctor can most likely check your
condition with a physical exam and by asking questions about your past health.
In some cases, an
X-ray,
CT scan, or
MRI is also used to check for bone or soft tissue
problems related to symptoms of TMD.
How is it treated?
TMD symptoms usually go
away without treatment. Simple home treatment can often relieve mild jaw pain.
There are things you can do at first to reduce pain.
Rest your jaw joint.
Use
medicines for a short time, to reduce swelling or relax muscles.
Put either an ice pack or a warm, moist cloth on your jaw for 15 minutes
several times a day if it makes your jaw feel better. Or you can switch back
and forth between moist heat and cold. Gently open and close your mouth while
you use the ice pack or heat.
Eat soft foods. And avoid
chewy foods and chewing gum.
Getting physical therapy and learning ways to reduce
stress may also help to reduce pain and TM joint problems. Continue to use some
of these methods over time to prevent and manage symptoms that might come back.
If your pain is chronic or severe or is caused by problems with how the joint
is shaped, your doctor may recommend other treatments.
Splints,
also called bite plates, are a common dental treatment for TMDs. Splints
are usually clear pieces of plastic that fit between the upper and lower teeth.
They help reduce grinding and clenching. Splints are used for a short time so
that they do not cause permanent changes in the teeth or jaw.
Before you try treatments such as surgery or reshaping or shaving down
the teeth, think it over. These treatments cannot be reversed and can even
damage the TM joint.
For most people, surgery is not used to treat
TMDs. Surgery has few benefits, and there is the chance of causing more
serious problems. You and your doctor can carefully weigh a decision to have
surgery. Talking with another doctor to get a second opinion can also help you
make your decision.
Chronic pain can lead to
depression,
anxiety, and other problems. If you have chronic pain,
talk to your doctor about medicine and mental exercises to manage the pain.
Give special attention to treating any related anxiety or depression.
Temporomandibular disorders (TMD) can result from a single cause or, more commonly, a
combination of causes.
The main causes of TMDs
include:
Muscle tension (tightness) and spasm. Muscle
tension in the jaw, face, head, neck, and shoulders may make your jaw feel
achy, stiff, and painful, especially when moving your jaw. Muscle tension may
be:
Caused by stress and anxiety and by
stress-related habits, such as daytime or nighttime clenching or grinding of your
teeth (bruxism), excessive gum chewing, or nail biting.
Degenerative disease, such as
osteoarthritis or
rheumatoid arthritis, which causes
inflammation and destruction of the joint tissues.
Scar tissue or bone damage caused by accidental injury or a blow
to the jaw.
Disease, such as a tumor, or structural problems
present at birth (congenital).
In many cases, TMD symptoms appear to be caused by both muscle tension (tightness) and
joint dysfunction. It is not always clear which came first. For example,
osteoarthritis can cause changes in the joint, which may then bring on muscle
spasms. Conversely, muscle spasms over time hinder jaw function and can
eventually cause osteoarthritis in the jaw joint. A similar relationship
appears to exist between muscle tension and disc displacement within the
joint.
When jaw joint problems are caused by diseases such as
rheumatoid arthritis, treatment for that condition is important. Many
other conditions cause symptoms similar to those of TMDs, such as
migraine headaches and infections.
Symptoms
Symptoms of
temporomandibular disorders (TMDs) are usually mild and
temporary and typically do not get worse with time. Common symptoms
include:
Joint pain when the jaw is moving, as when
opening the mouth widely, chewing, or yawning. Such pain can occur:
Usually on one side of the jaw, but it can
be on both sides.
Either gradually or suddenly, as when biting
down on something hard or following a blow to the jaw.
Headaches. In children with TMDs, headaches
are often related to grinding the teeth (bruxism).
Clicking, popping, cracking, or
grating that is painful and occurs when opening the jaw (may be a sign of
disc displacement). Clicking or popping noises without pain are common and do
not require treatment.
The jaw locking in an open or closed
position or not opening wide (disc displacement). If the jaw locks for more
than a few moments, a muscle spasm usually follows.
Sometimes pain
around the ear, with pressure or ringing in the ears (tinnitus), develops with
TMDs. Some people with these symptoms report that they also have
hearing loss, although test results show that their hearing is normal.
Symptoms often go away on their own. And they may recur over time without
getting much better or worse. Occasional discomfort in the jaw joint or chewing
muscles is quite common and usually is not a cause for concern. But for some people symptoms can be
very painful, disabling, and last a long time.
What Happens
The course of
temporomandibular disorders (TMDs) caused by muscle
tension varies depending on the cause of the muscle tension.
If muscle tension is related to a one-time
overuse injury (such as holding your mouth open for a long time during a dental
exam), the pain and discomfort may go away without treatment.
If there is long-lasting (chronic) muscle tension
due to stress, anxiety, an injury or blow to the jaw, or habits like grinding
the teeth during sleep, treatment (including changing certain habits) may
relieve pain and discomfort. If chronic muscle tension is not treated, it may
gradually cause changes in the joint structure or
osteoarthritis.
Respond well to nonsurgical treatment, if
treated early.
Get worse, if not treated. Long-term consequences
include injury to the disc or other tissues in the joint, arthritis, or chronic
pain.
Chronic pain
In some cases, TMDs can be
extremely painful and disabling and last a long time. Such
chronic pain can affect a person's overall quality of
life by increasing stress, making it hard to do a job, and
interfering with personal life.
Depression and
anxiety are common results of chronic pain. Treatments may not relieve pain due to the lasting
psychological and biological impact of
chronic pain. These biological effects can lead to a sense of helplessness and biochemical
changes in the body that perpetuate pain. In these
cases, it is especially important to seek treatment for TMD pain and
for related depression and anxiety.
What Increases Your Risk
Risk factors for
temporomandibular disorders (TMDs) include:
Stress and anxiety, which can cause facial and
jaw muscle tension.
Repetitive habits, such as grinding your teeth
(bruxism), clenching your teeth, excessive gum chewing,
eating hard or chewy foods, and nail biting.
Habits that can cause
muscle tension, such as sleeping on one side of your face or with your mouth
open, opening your mouth wide when yawning or singing, or holding your head up
by cradling your jaw in your hand.
Injury to the jaw or head. TMDs can result from a direct blow to the jaw, chin, or head;
whiplash to the head or neck; overstretching the jaw
during dental work or surgery; or other injuries that may lead to joint damage
or muscle tension.
Age and gender. TMDs are more common in
younger adults (ages 20 to 50) and in women.footnote 1
When To Call a Doctor
Call your dentist or doctor immediately if you have had an
injury to your jaw or face and:
Your jaw is very painful.
Your jaw
is locked open or shut, or you are unable to move your jaw easily or smoothly
(a sign of
disc displacement, dislocation, or fracture).
Your jaw appears to
be deformed or swollen.
There is swelling in the sides of your
face.
Your teeth no longer fit together normally when biting down
(malocclusion).
A severe headache or neck ache strikes suddenly,
without apparent cause, or is different from previous headaches.
Call your dentist or doctor if
you:
Have pain when moving your jaw (biting,
chewing, swallowing, talking, or yawning) that is not getting better after 2
weeks of home treatment.
Have had jaw pain for a long time
(chronic).
Have anxiety, stress, or work-related problems caused by
your jaw discomfort and pain.
Continue to have symptoms (such as
pain with clicking or cracking sounds or your jaw locks) after 2 weeks of home
treatment.
Notice a change in the way your teeth fit together when
you close your mouth.
Who to see
Your treatment for
temporomandibular disorder (TMD) may involve several
different health professionals.
If a doctor suggests that you try a
treatment that might make permanent changes to your jaw, be sure to get a second opinion.
Health and dental
insurance plans might not cover diagnosis and treatment. Because some
tests and treatments are quite expensive, you may want to
check your coverage before incurring expenses.
Currently there is no widely accepted
standard test for identifying the cause of
temporomandibular disorders (TMDs). But your dentist or
doctor will most likely be able to accurately diagnose your
condition with information from a
medical history and physical exam.
Most
TMDs are caused or made worse by muscle tension (tightness). Expect
your doctor to suggest treatment that does not involve surgery or
permanent changes to the jaw (conservative treatment) to relieve your jaw pain,
muscle tension, and TM joint problems.
If you have sudden pain
after a facial or jaw injury, your doctor is likely to order some
type of imaging test, such as an X-ray, a CT scan, or magnetic resonance
imaging (MRI).
If conservative treatment has not worked
If
conservative treatment has not worked and your jaw is locking in place (a sign
of disc displacement), your pain is severe or chronic, or
you have other medical problems, such as
rheumatoid arthritis, other tests may be needed. These
tests are usually done only if knowing their results could change your
recommended treatment plan.
If you still have symptoms after the
first period of treatment, your doctor may begin to look for
problems in the jaw joint structure. Other tests may include:
X-ray. This
test can confirm whether the bones are worn away, broken, or disfigured. If
disc displacement is suspected, X-rays may be helpful to show the size of the
joint space. A narrow joint space can be a sign that the disc is
affected.
Magnetic resonance imaging (MRI). A
view of the soft tissues (ligaments, muscles, and articular disc) is useful in
showing disc displacement or damage. Although expensive, MRI is thought to be the
most effective imaging technique for assessing TMDs that may involve
disc problems.
Treatment Overview
The goal of treatment for
temporomandibular disorders (TMDs) is to relieve pain in
the jaw and restore normal jaw movement and function. Several treatment
approaches are effective. The first treatments that are tried for TMDs are called conservative, because they are simple and temporary. They are not invasive or permanent. They can be stopped or reversed. They include over-the-counter pain medicine and self-care that you can do at home.
Often, simple home treatment measures can
successfully relieve jaw pain. Less than
1 out of 10 adults have jaw problems or pain that is so severe that they need medical or dental treatment.footnote 1
For chronic,
muscle-related TMDs, standard medical care can include muscle
relaxation measures,
biofeedback, stress management, or
cognitive-behavioral therapy.
For chronic pain caused by a TMD, it is important to seek treatment for pain and
for related depression and anxiety.
Dental splints are the most common dental
treatment for TMDs. These splints or bite plates are typically used for a short period of
time. They can help relieve muscle tension and pain.
Most people do not need permanent dental work or surgery. Permanent dental work might include orthodontic treatments involving permanent changes to
the jaw. At best, permanent treatments or surgery may not work any better than physical therapy and temporary treatments. At worst, they can cause irreversible damage. If your doctor recommends surgery or other treatment that involves permanent
changes, be sure to get a second opinion before you start treatment.
Often, structural problems in
the jaw, such as
disc displacement, can be improved with conservative (nonsurgical) treatment,
especially when they are treated early.
Health and dental
insurance plans might not cover diagnosis and treatment. Because some
tests and treatments are quite expensive, you may want to
check your coverage before incurring expenses.
Prevention
To prevent
temporomandibular disorders (TMDs), try to reduce muscle
tension in your jaw. You can reduce muscle tension in these ways:
Relax. If you have a lot of stress and anxiety
in your life, try relaxation techniques. See the topic
Stress Management.
Learn to recognize when
you are clenching your teeth. Practice keeping your teeth apart, bringing them
together only when swallowing or eating. When driving, avoid clenching the
wheel with both hands, because often your teeth will be clenched also.
Do not overuse and stress your jaw muscles. Avoid constantly
chewing gum, biting your nails, resting your chin on your hand, or cradling the
telephone receiver between your shoulder and jaw.
Change your diet.
Eat softer foods, and use both sides of your mouth to chew your food. Avoid
hard or chewy foods, such as popcorn, apples, carrots, taffy, hard breads, and
bagels.
Maintain good posture. Poor posture may disturb the natural
alignment of your facial bones and muscles, causing pain.
In the past, various procedures such as dental restoration
and orthodontic treatment were used to prevent joint sounds from developing
into TMDs. Such measures are not only unneeded but also
potentially damaging to a joint that may never become painful on its
own.
See Home Treatment for other ways
to prevent or reduce muscle tension in your jaw.
Home Treatment
If your
temporomandibular disorder (TMD) symptoms are mild, try
home treatment for at least 2 weeks. If your symptoms don't get better or if they get worse during this
time, call your doctor or dentist.
Home treatment
involves reducing your stress, resting your jaw (by eating only soft or pureed
foods), taking steps to reduce pain, and exercising your jaw.
To
help relieve pain and restore jaw function:
Try comfort measures such as moist heat, ice, or nonsteroidal
anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen.
Do jaw exercises as prescribed by your doctor or physical
therapist. Also, pay attention to your jaw, and relax it when you are tense.
Change your diet to
decrease jaw strain. For example, avoid hard or chewy foods.
Manage stress. Many people tend to clench or tighten their muscles when they
are under stress of any kind.
If you have been diagnosed with a TMD, these home
treatment measures will optimize the treatments prescribed by your doctor or dentist, such as a
splint therapy or physical therapy.
Medications
You can use medicine to relieve the
pain of a
temporomandibular disorder (TMD). Short-term use of
nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, muscle relaxants, or
antidepressant medicines can relieve or reduce
inflammation, control pain, and relax the jaw muscles.
Be safe with medicines. Read and follow all instructions on the label.
Opioid pain relievers (such as acetaminophen with
codeine or hydrocodone) are used in some cases of acute, severe pain. Because
opioids are addictive, they are usually not taken long-term.
Muscle relaxants, such as cyclobenzaprine (Flexeril) or diazepam (Valium), are used in some cases of acute pain or prolonged
muscle spasm. Because they are addictive, sedating, and can cause depression or
make it worse, muscle relaxants should be taken at the lowest possible dose and
are usually not used long-term.
Low doses of tricyclic antidepressants, such as amitriptyline,
are used in cases of chronic pain. These
medicines might also be used if you have a disrupted sleep pattern,
which can cause you to grind your teeth
(bruxism).
What to think about
Nonsteroidal anti-inflammatory
drugs (NSAIDs) do not cure TMDs. But they may reduce pain and
inflammation, which allows you to do prescribed jaw exercises that can start
the healing process. NSAIDs may be prescribed on a regular basis for 1 to 2
weeks to help reduce inflammation even though the pain has subsided.
Your doctor may prescribe an antidepressant, not necessarily because you
suffer from depression but to help treat chronic pain or nighttime
bruxism.
Surgery
Surgery is rarely used to treat
temporomandibular disorders (TMDs). Surgical treatment
does not guarantee a cure and can further damage the temporomandibular joint.
Because most TMDs can be treated nonsurgically, most doctors believe that surgery should be the last option tried and should
be avoided if possible.
Surgery may be a treatment option for you
if both of the following apply:
Other treatments have failed, and chronic jaw
pain and dysfunction have become disabling.
There are specific,
severe structural problems in the jaw joint. These include scar tissue in the
joint area, problems with bone alignment, broken or degenerated bones, and
occasionally
disc displacement or perforation.
Arthrocentesis. This is not a true
surgery, since there is no incision. But it is an invasive procedure done
by an oral and maxillofacial surgeon.
Surgery may include:
Arthroscopic
procedures, including washing out the joint area (lavage), cutting or removing
scar tissue that is blocking joint movement (lysis), cutting tissue that has
shortened and is impeding joint function, or shaving part of the
disc.
Open joint arthroplasty, used for disabling joint
problems that aren't easily reached or viewed arthroscopically.
Another type of surgery, called total joint replacement,
is rarely done. It has sometimes resulted in permanent jaw damage. Total joint
replacement replaces the jaw joint with artificial parts. In some cases the
artificial parts have not worked correctly or have broken. The available
technology for this surgery is still considered to be experimental and
risky.
What to think about
Further pain complications or
joint dysfunction can result from temporomandibular joint surgery.
Surgery is not needed in most
cases of disc displacement.footnote 2 Splint therapy (a
dental treatment), jaw rest, and physical therapy, including moist heat and jaw
exercises followed by an ice pack, can work very well for treating this
condition. If this and other nonsurgical treatment to relax the muscles are not
successful, arthrocentesis may effectively treat your condition.
If you are thinking about surgery, get a second opinion on your condition
and treatment.
Other Treatment
Many types of treatment can
successfully relieve
temporomandibular disorder (TMD) symptoms. Different
doctors will suggest different treatments, any of which may work
to relieve jaw and facial pain.
If a doctor
recommends that you try a treatment that might make permanent changes to your
jaw or teeth, get a second opinion.
Other treatment choices
Depending on your condition, one of the following choices
may be more effective than another. Safe options for treatment of TMD
include:
Some
dental treatments, including splint therapy to relieve
pressure on the TM joint.
Many different types of
treatment for temporomandibular disorders (TMD) have potential for successfully
relieving your condition. If your problem is linked to muscle tension, any
treatment that helps you relax your jaw muscles with no adverse effects is
likely to be helpful. Different treatments work for different people.
Treatments vary greatly in safety, cost, and how well they work.
Other Places To Get Help
Organization
National Institute of Dental and Craniofacial Research (U.S.)
Scrivani SJ, et al. (2008). Temporomandibular disorders. New England Journal of Medicine, 359(25): 2693-2705.
Tucker MR, et al. (2008). Management of temporomandibular disorders. In JR Hupp et al., eds., Contemporary Oral and Maxillofacial Surgery, 5th ed., pp. 629-649. St. Louis: Mosby Elsevier.
Other Works Consulted
Goddard G (2008). Temporomandibular disorders. In AK Lalwani, ed., Current Diagnosis and Treatment in Otolaryngology - Head and Neck Surgery, 2nd ed., pp. 389-396. New York: McGraw-Hill.
American Academy of Pediatric Dentistry (2010). Guideline on acquired temporomandibular disorders in infants, children, and adolescents. American Academy of Pediatric Dentistry Clinical Guidelines Reference Manual, 32(6): 232-237. Also available online: http://www.aapd.org/media/policies.asp.
American Association for Dental Research (2010). Temporomandibular Disorders (TMD). Available online: http://www.aadronline.org/i4a/pages/index.cfm?pageid=3465#TMD.
American Society of Temporomandibular Joint Surgeons (2003). Guidelines for diagnosis and management of disorders involving temporomandibular joint and related musculoskeletal structures. Cranio, 21(1): 68-76.
Okeson JP (2011). Temporomandibular disorders. In ET Bope et al., eds., Conn's Current Therapy 2011, pp. 1008-1011. Philadelphia: Saunders.
Credits
ByHealthwise Staff Primary Medical ReviewerAdam Husney, MD - Family Medicine Martin J. Gabica, MD - Family Medicine Kathleen Romito, MD - Family Medicine
Scrivani SJ, et al. (2008). Temporomandibular disorders. New England Journal of Medicine, 359(25): 2693-2705.
Tucker MR, et al. (2008). Management of temporomandibular disorders. In JR Hupp et al., eds., Contemporary Oral and Maxillofacial Surgery, 5th ed., pp. 629-649. St. Louis: Mosby Elsevier.
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