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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 7
| Issue : 4 | Page : 111-114 |
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Temporomandibular disorders: An updated review
M Nazargi Mahabob
Associate Professor, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Faisal University, Al Ahsa, Kingdom of Saudi Arabia
| Date of Submission | 08-Sep-2020 |
| Date of Acceptance | 03-Oct-2020 |
| Date of Web Publication | 29-Dec-2020 |
Correspondence Address:
Dr. M Nazargi Mahabob
Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, College of Dentistry, King Faisal University, Al Ahsa 31982
Kingdom of Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijpcdr.ijpcdr_42_20
A group of conditions related to temporomandibular joint (TMJ) is called as “temporomandibular disorder” (TMD). Several attempts were made to classify TMD based on the frequency of occurrence, etiology, and anatomy, but they have had some shortfalls, and one mostly accepted is diagnostic criteria/TMD classification. TMD is a group of clinical problems; it involves either TMJ or its associated structures separately or combination. Any factor that affects one part of the system is likely to have an impact on the other parts also, so it is essential to approach carefully when considering likely signs and symptoms of TMD. About 20%–30% of the adult populations are affected to some degree of TMD, and it is predominately affected young and middle-aged adults. The prevalence rate of TMD problems twice common in females than the males. The etiology of TMD is inconclusive, and now, it has been accepted that multiple factors play a role in TMD. Since it is multifactorial, treatment should be planned according to that and varies patient to patient. Majority of the patients having mild-to-moderate TMD and conservative treatment approach over surgery results in satisfactory outcomes. The aim of this review is to evaluate the recent updates and propose solutions for patients with TMD.
Keywords: Orofacial pain, psychosocial factors, physiotherapy, socioeconomic, surgery, temporomandibular disorders
How to cite this article:
Mahabob M N. Temporomandibular disorders: An updated review. Int J Prev Clin Dent Res 2020;7:111-4 |
| Introduction | |  |
Temporomandibular disorder (TMD) is a term used to define a group of disorders that associated with either temporomandibular joint (TMJ) or masticatory muscles or both.[1],[2] TMD can be associated with impaired general health, depression, and other psychological disturbances and may affect the lifestyle of the patient. Even though approximately 40%–75% of the people experiencing at least one type of TMD problem, only 3%–7% of people seek treatment. The majority of those affected are young and middle-aged individuals ranging from 25 to 45 years, and it occurs three to five times more in women than men.[1] The difference for the wide discrepancy among the number of individuals presenting with subjective signs and symptoms remains unclear. Pain not only has precise anatomical, physical, and pathological dimensions, but also it is influenced by cultural or other components in its expression and manifestation and gives different understanding from the social or cultural perspective. It is due to the psycho, social, and cultural dimensions of understanding and his or her sociodemographic characteristics.
| Anatomy | | |
The joint involves fibrocartilaginous surfaces and an articular disc that divides the joint into two cavities. These articular cavities are lined by separate synovial membranes. The articular disc is a fibrous extension of the capsule that runs between the two articular surfaces of the temporomandibular joint. The disc attached to the condyle medially and laterally by the collateral ligaments. The anterior disc attaches to the joint capsule and the superior head of the lateral pterygoid. The posterior portion attached to the mandibular fossa and referred to as the retrodiscal tissue. Unlike the disc, the retrodiscal tissue is vascular and highly innervated. As a result, the retrodiscal tissue is often a major contributor to the pain of TMD, particularly when there is inflammation or compression within the joint. The ligaments give needed stability to the TMJ. The otomandibular ligaments may be behind in tinnitus associated with TMD.[3],[4],[5]
| Etiology | | |
Both specific and nonspecific factors are there for TMJ-related problems, which continue to be controversial. The controversy is happening due to some of them are risk factors, and others are either causal or coincidental. Although the etiologies are poorly understood, most clinicians and researchers have agreed that the etiology of TMD is multifactorial and involves biologic, environmental, social, emotional, and systemic problems such as rheumatoid arthritis, inflammatory conditions, ankylosing spondylitis, and lupus also precipitating.[2]
| Classification | | |
Previously, several attempts were made to classify the TMD using different criteria. In 2013, the International Research Diagnostic Criteria for Temporomandibular Dysfunction Consortium Network published an updated classification structure for TMD, and recently published Diagnostic Criteria for TMD (DC/TMD) is the revised version of the RDC/TMD.[6] It comprises two axes; one is physical Axis I for diagnosis and another one is psychosocial Axis II for psychosocial assessment. Application of the RDC/TMJD allows uniformity in registering the signs and symptoms of patients with TMJD, thereby ensuring precision in the study of this disease.
| Clinical Signs and Symptoms | | |
In patients with TMD, orofacial pain may be dull or sharp and occurs when the patient swallows, talks, or chews. Often, the pain originates in the periauricular area; however, it may radiate to other locations of head and neck. In severe cases, crepitus, a crackling, or crushing noise occurs, and the patient often has restricted jaw opening ability. There may be tenderness on palpation around the periauricular region, temple area, cheek, mandible, and teeth associated with the spasm of adjacent muscles of the face and jaws with pain.[3]
| Clinical Evaluation and Diagnosis | | |
Clinical examination of the patient involves the assessment of the range of mandibular movement by recording the interincisal distance between maxillary and mandibular incisors opening with the help of a ruler or caliper. Minimum of normal is a 40 mm opening, 7 mm to the right and to the left movements, and a 6 mm protrusive movement. In addition, bilateral auscultation of TMJ noises and gentle digital palpation of the joints and masticatory muscles should be performed. In patients with chronic TMD, behavioral, social, and emotional assessments should be performed.[7]
| Radiographic Investigations | | |
The initial study should be with conventional radiographic techniques or panoramic radiography. In comparison to conventional and panoramic radiographs, three-dimensional cone-beam computed tomography is superior for evaluation of bony morphology. Magnetic resonance imaging is the golden standard for comprehensive joint evaluation in patients with signs and symptoms of TMD. When magnetic resonance imaging is not available, even though it is not matching, ultrasonography performs as a low-cost alternative technique to diagnose internal derangement of the TMJ.[8]
| Treatment | | |
The need for TMD treatment in the general adult population varies according to the definition, selection criteria, age, and gender. Initial treatment goals should focus on resolving pain and dysfunction. Management of TMJ dysfunction may involve the use of medications [Table 1] or other nonsurgical or surgical options [Table 2].
| Nonpharmacological Management | | |
Self-management
For the success of any treatment, patients' cooperation and involvement needed. The some of the following recommendations can be given to patients to practice encouragement of patients to rest their masticatory muscles, avoidance of parafunctional habits and excessive mandibular movements, intake of soft diet and careful chewing with simultaneous bilateral mastication, and maintaining proper sleeping posture.[4],[5] Physical therapy: the focus of physical therapy for TMDs is relaxation, stretching, and releasing tight muscles and scar tissue.[9] Biofeedback: it plays a role in the management of TMD by alerting patient if there is an excessive and inappropriate muscle activity and teaches proper movements of TMJ by helping to develop muscle relaxation skills. Electrotherapy: this technique can be applied to reduce pain and improve function in patients with TMD. Some of them are transcutaneous electrical nerve stimulation, pulsed radiofrequency energy, lower-level laser therapy, and shock waves.[10] Acupuncture: it is applied at specific body points with the aim of influencing the physiological functions of the body. Acupuncture reduces pain sensation through direct stimulation of the nerve, which changes the quality of signal along with nerve cells. Several studies have demonstrated that the acupuncture is an effective therapeutic intervention for orofacial pain.[11]
Dental treatment
Dental treatments are based mainly on the use of intraoral orthopedic devices, which are called orthoses or occlusal splints, occlusal corrections, and rehabilitation.[12] Occlusal splints: splints are thought to work by in effect protecting the TMJ. Although there are varying designs, and they all function similarly. Splints should not be used in patients with intermittent locking or in small symptomatic that can promote its progression or blockade. Occlusal adjustment: if there is no proven causal relationship between malocclusion and the TMD, there is no justification for performing an irreversible occlusion procedure in patients under the guise of a therapeutic purpose.[13] Orthodontics: orthodontics is one of the effective approaches often used with TMJ disorder. If TMD is caused by misalignment or bite problems, braces can be used to move your teeth back into the normal position. This will reduce or even eliminate symptoms as well as prevent abnormal wear and tear to teeth.
Pharmacologic management
In the management of TMD related pain conditions nonsteroidal inflammatory drugs act as the first-line agents. Muscle relaxants such as benzodiazepines and antidepressants such as amitriptyline can be tried, as they are often effective in other chronic pain disorders. Opioid is not recommended for the management of chronic TMD pain because the risk of developing drug dependency. Pharmacologic treatment works with other treatment modalities often plays an important role in the management of articular disk and TMJ disorders.[14]
| Invasive Treatment Options | | |
Injected pharmacotherapy: study results supported the use of intraarticular injection with corticosteroids and sodium hyaluronate seems to be an effective method for treating internal derangements of the TMJ. The corticosteroids have an anti-inflammatory effect, and the hyaluronate could improve the joint's lubrication. Whenever other noninvasive treatments are not giving satisfactory results, BTX injection method can be tried as an alternative treatment option for TMD.[15] Arthrocentesis and arthroscopy: these are minimally invasive methods of treatment, located between conservative and surgical therapy, i.e., minimally invasive technique. They performed under local anesthesia on outpatients and used for acute open or closed lock caused by articular disc displacement and for degenerative inflammatory joint disease treatment. Open surgical procedures: some of the open surgical procedures are disc repositioning, discectomy, disc replacement, TMJ prosthesis, arthroplasty, and total joint replacement.[16] These procedures are used after the failure of conservative management.
| Conclusions | | |
Since multiple factors plays role in imitation and progression of TMD, it is a complex musculoskeletal disorder. Physical, behavioral, and emotional factors overlap and interact in TMD. Proper clinical assessment and diagnosis of TMD are important to rule out disorders that mimic TMD, to identify non-TMD disorders that may negatively influence the patient's TMD symptoms, and to offer the patient therapies that will provide the most cost-effective long-term symptom relief.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Table 1], [Table 2]
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