Temporomandibular Joint Pain

Temporomandibular joint pain is pain in the jaw joint, the muscles of mastication or both, part of a group of temporomandibular disorders. It is the commonest cause of non-dental orofacial pain, and presents with pain on chewing, joint noises and limited jaw movement.

• Types: myofascial pain of the masticatory muscles (the commonest), arthralgia, disc displacement with reduction (clicking), disc displacement without reduction (with limited opening, a closed lock), degenerative joint disease (osteoarthritis), and hypermobility or dislocation.
• Prevalence of symptoms is about 5 to 12 percent of adults; peak age is 20 to 40 years; women are affected 2 to 3 times more often than men.
• Factors: bruxism and clenching, parafunctional habits (gum chewing, nail biting, cheek biting), trauma (blow, whiplash, wide yawning, dental procedures), stress, anxiety and depression, poor sleep, generalised joint laxity, rheumatoid and other inflammatory arthritis, and psychosocial factors.
• Chronic widespread pain (fibromyalgia), headache and irritable bowel syndrome commonly coexist.

• Pain in the preauricular region, cheek, temple or ear, worse with chewing, yawning, talking and clenching, often worse in the morning (clenching) or evening (muscle fatigue).
• Jaw noises: clicking, popping or crepitus.
• Restricted mouth opening (under 35 to 40 mm; normal is 40 to 55 mm), deviation of the jaw on opening, locking (open or closed), a sense that the bite has changed.
• Associated: headaches (temporal), ear fullness, tinnitus, dizziness, neck and shoulder pain, tooth ache without a dental cause, facial fatigue.
• Examination: palpate masseter, temporalis, medial and lateral pterygoid muscles, and the joint (preauricular and through the ear canal); measure maximum unassisted opening and lateral movement; observe for deviation; listen for clicks and crepitus; examine teeth for wear, occlusion and dentition; check the neck.
• Red flags: trismus after infection or radiotherapy, fever, swelling, facial weakness, numbness, history of cancer, jaw claudication with scalp tenderness and visual symptoms in a patient over 50 (giant cell arteritis), sudden bite change after trauma (fracture), or progressive facial asymmetry.

• Clinical, based on history and examination; reproduce the pain by palpation or jaw movement.
• Imaging is not needed for most patients. Panoramic radiograph for gross bony changes and dental disease; MRI to show disc position and joint effusion when mechanical derangement or a closed lock is suspected and treatment would change; CT or cone beam computed tomography for bone changes, fracture, ankylosis or tumour.
• Blood tests when inflammatory arthritis or giant cell arteritis is possible: ESR, CRP, rheumatoid factor, anti-cyclic citrullinated peptide antibodies, uric acid.
• Screen for depression, anxiety, sleep problems, and other pain conditions.
• Differentials: dental pain (caries, pulpitis, cracked tooth), sinusitis, otitis media and externa, parotitis or salivary stone, trigeminal neuralgia, giant cell arteritis, cervicogenic headache, migraine, tension type headache, cluster headache, fracture or dislocation, ankylosis, tumour, infection (septic arthritis), and rheumatoid, psoriatic or juvenile idiopathic arthritis.

Education and self-care (first line for all)

• Reassure that most cases settle or stabilise in weeks to months and rarely progress; avoid unnecessary imaging and irreversible dental treatments.
• Soft diet for 2 to 4 weeks, cut food into small pieces; avoid chewing gum, ice, hard or tough foods, and wide yawning (support the jaw with a hand).
• Keep teeth apart and lips together at rest (the jaw at rest posture); identify and stop clenching, grinding, nail biting and cheek biting; relaxation and stress management; good sleep posture (avoid sleeping on the stomach or with the hand on the jaw).
• Heat (moist heat for 15 to 20 minutes) for muscle pain; cold packs for acute joint pain or swelling for 10 minutes.
• Jaw exercises: gentle opening, stretching and resisted opening and closing as directed by a physiotherapist, 5 to 10 repetitions several times daily.

Medicines (short term)

• Ibuprofen 400 mg orally three times daily with food for 1 to 2 weeks, or naproxen 250 to 500 mg twice daily with food; topical diclofenac 1 percent gel to the joint area three to four times daily; paracetamol 1 g up to four times daily (maximum 4 g).
• Muscle relaxation for severe muscle spasm: diazepam 2 mg orally at night for no more than 1 to 2 weeks, or cyclobenzaprine 5 to 10 mg at night for 2 to 4 weeks where available (sedation; avoid with alcohol, and in older adults).
• Chronic myofascial pain: amitriptyline 10 mg at night increasing by 10 mg every 1 to 2 weeks to 25 to 50 mg; duloxetine 30 to 60 mg daily; gabapentin 300 mg at night increasing to 300 to 600 mg three times daily.
• Avoid opioids and long term benzodiazepines.

Physical and appliance therapy

• Physiotherapy (manual therapy, posture, jaw exercises, ultrasound, transcutaneous electrical nerve stimulation, dry needling or trigger point injections with lidocaine 1 percent 0.5 to 1 mL).
• Stabilisation (occlusal) splint: a hard acrylic, full arch splint worn at night (and by day for severe pain) for 3 to 6 months, made by a dentist; supports bruxism and muscle pain; stop if the bite changes.
• Cognitive behavioural therapy and biofeedback for chronic pain, stress and parafunction.

Joint treatments (specialist)

• Closed lock: manual manipulation, then arthrocentesis (lavage) with or without injection of hyaluronic acid 1 mL or corticosteroid (for example methylprednisolone 20 mg; limit repeats to avoid cartilage damage).
• Botulinum toxin A 20 to 50 units into masseter and temporalis for refractory myofascial pain and bruxism.
• Arthroscopy and open surgery (disc repositioning, discectomy, joint replacement) only for severe, refractory structural disease after failed non-surgical care.
• Acute dislocation: manual reduction (thumbs on lower molars, pressing down and back), then support with a bandage for 24 hours and advice to avoid wide opening for 2 to 4 weeks.

Avoid

• Irreversible occlusal adjustment, orthodontics and extractions as a treatment for jaw pain.

Follow up

• Review at 2 to 4 weeks and 3 months; refer to oral and maxillofacial surgery or orofacial pain specialists if there is persistent locking, progressive limitation, pain unresponsive to 3 months of conservative care, or red flags.