Temporomandibular Joint Disorders

Clinical Presentation

Clicking, popping, or grating sounds (crepitus) when opening or closing the mouth, which may or may not be accompanied by pain, are common symptoms in patients with temporomandibular joint (TMJ) disorders, according to the American College of Radiology 1
TMJ disorders are a group of conditions that cause pain and dysfunction in the jaw joint and surrounding muscles, affecting various populations, including those with Ehlers-Danlos Syndrome (EDS), with symptoms including clicking or popping sounds in the temporomandibular joint, restricted mandibular mobility, pain in the masticatory muscles, and temporal headaches that may radiate to ear and neck regions 2, 3, 4, 5

Clinical examination should precede imaging in the diagnostic sequence to avoid overreliance on imaging, as suggested by the American College of Radiology and the American College of Rheumatology 3, 6
Dedicated MRI of the temporomandibular joint may be considered if TMJ pathology is suspected, according to the American College of Radiology 7
Contrast-enhanced MRI is best for detecting active TMJ inflammation, while CBCT or CT scan is indicated for TMJ bone disease assessment, and panoramic radiographs are not diagnostically useful for TMJ disorders, as stated by the American College of Radiology, the American College of Rheumatology, and the European Society of Radiology 3, 6, 1
The American College of Radiology recommends MRI when there are concerning features such as unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 7

Conservative management should be first-line for TMJ disorders with associated ETD symptoms, including occlusal splints/stabilization splints, physical therapy, and jaw exercises, as well as manual trigger point therapy targeting masticatory muscles, as recommended by the Arthritis and Rheumatology society and the American Dental Association 6
Applying moist heat for 10-15 minutes several times daily and alternating with cold therapy (ice wrapped in towel) for 10-minute periods can help relax muscles and reduce acute inflammation, as recommended by the American Academy of Family Physicians 2
Implementing relative rest of the TMJ, with a soft or liquid diet, avoiding wide mouth opening, and minimizing jaw movement is recommended 2
Education and self-management strategies, including jaw rest, soft diet, and application of heat and/or cold, should be pursued first for TMJ disorders, as recommended by the American College of Rheumatology 3, 8, 9

Acetaminophen may be used for breakthrough pain, though evidence suggests limited efficacy when used alone 3
Optimizing NSAID therapy with scheduled doses for short-term pain relief, considering higher anti-inflammatory doses of ibuprofen (600-800mg every 6-8 hours) or naproxen (500mg twice daily), is recommended by the American Academy of Family Physicians 2, 3
NSAIDs combined with opioids is strongly recommended against for acute TMJ pain management 3
Gabapentin is conditionally recommended against for acute TMJ pain management 3
A short course of benzodiazepines may be considered for acute management despite conditional recommendation against long-term use, based on the patient's response to oral diazepam 3

Arthrocentesis has a high success rate of 77% for chronic closed lock, with significant improvements in jaw opening and mandibular function and a low complication rate of 8% [@6@]
Arthroscopic lysis and lavage has shown increased mouth opening from mean 27mm to 38mm, with a 77% success rate and short hospital stay, and is recommended for chronic closed lock unresponsive to conservative therapy [@7@]
Surgical interventions should only be considered after exhausting all conservative options, with a stepped approach starting with conservative measures and progressing to more invasive procedures as needed [@8@]
Total TMJ replacement should only be considered when joint collapse or fusion has occurred, or when other treatments have failed to provide adequate symptomatic control, with caution for metal hypersensitivity and a risk of surgical site infections at 0.7% 4

Patients with TMJ disorders should be referred to a multidisciplinary team that includes oral and maxillofacial surgeons, oral medicine specialists, physiotherapists, and maxillofacial prosthetists, with access to psychiatry services as needed, as recommended by the American Association of Oral and Maxillofacial Surgeons 6
Early referral to rheumatology and specialized TMJ services is recommended for patients with TMJ arthritis, with consideration of systemic immunosuppressive therapy, which has shown beneficial effects on TMJ arthritis and mandibular growth, as suggested by the American College of Rheumatology 6
Longitudinal evaluation into adulthood is recommended for juvenile patients with TMJ arthritis, regardless of current TMJ disease activity, as recommended by the American College of Rheumatology 6
Active participation by patients is crucial for the success of most recommended interventions, considering their preferences, cost, and access to therapy 3
Shared decision-making is essential to ensure treatment aligns with patient values and preferences for TMJ disorder patients, as noted by the British Medical Journal guidelines and the American College of Rheumatology 3, 8, 9