Temporomandibular disorders include disorders of the temporomandibular joint (TMJ), masticatory muscles and accompanying structures. The most common symptoms of temporomandibular joint dysfunction syndrome are joint pain, clicking, reduced ability to open the mouth. Most often, these disorders are a result with trauma.
The fact that people constantly talk or eat makes the jaw joint one of the most commonly moved joint. Pain in this part of the head is part of the temporomandibular joint syndrome: myofascial painful dysfunction.
Diagnosis can sometimes be extremely difficult because a large number of diseases can affect the joint and associated structures. For example autoimmune diseases, infections, benign and malignant tumors, fractures, congenital and acquired diseases, etc. Also because many other diseases (headaches, pulpitis, denticio difficilis, sinusitis, etc.) can have similar symptoms.
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What is temporomandibular joint dysfunction syndrome?
The first definition of the disease was given by James Costen, an otorhinolaryngologist from the United States. In the 1930s he was the first to draw attention to the association of middle ear pain with maxillary pathologies in patients. Therefore, the syndrome of temporomandibular joint dysfunction is also called Costen’s syndrome.
Costen’s syndrome is a dysfunction of the temporomandibular joint (the joint that connects the lower jaw and the skull). It is accompanied by severe pain and can affect the surrounding muscles and soft tissues. In other words, it is a pathology of the muscles of the face, lower jaw, and the joint that connects it to the skull.
As many as two-thirds of people have symptoms of temporomandibular joint dysfunction at some point in their lives. Normal movements, such as yawning widely or eating a large piece of food, can cause facial pain or a feeling of jaw popping. This temporary ailment usually goes away on its own, without any treatment or responds quickly to resting or taking pain medication. But some patients experience pain that spreads to the face, neck and shoulders. In this case it is a chronic form of temporomandibular joint syndrome and occurs as a result of some other diseases.
In most cases, the temporary discomfort caused by Costen’s syndrome can be cured by using cheap, home-made preparations, but for a small number of patients, constant and sometimes unbearable pain is a serious problem that needs to be treated by a doctor.
Causes of temporomandibular joint dysfunction syndrome
Scientists believe that TMJ dysfunction develops under the influence of many factors. The temporomandibular joint belongs to the “target organs” that correspond to aggression factors of different origins. Therefore, they can be local and systemic. Local factors include acute and chronic joint injuries, lack of chewing teeth, bruxism (gnashing of teeth in sleep). TMJ dysfunction syndrome can develop under the influence of stress, anxiety, tension and other emotional factors.
Major theories of TMJ dysfunction include occlusive articulation, myogenic, and psychogenic. According to the theory of occlusive articulation, the causes of temporomandibular joint dysfunction are dental disorders. For example, dentition defects, abnormal tooth abrasion, jaw injury, an improper bite, improper prosthetics, various tooth anomalies and tooth decay.
According to myogenic theory, the development of TMJ dysfunction is stimulated by disorders of maxillary muscles: tonic spasm, mechanical overload of masticatory muscles, etc. Also, unilateral type of chewing, bruxism, bruxomania, occupations associated with high speech load, which ultimately leads to chronic microtrauma of the temporomandibular joint.
Psychogenic theory examines the etiopathogenesis of TMJ dysfunction based on the fact that the factors initiating TMJ dysfunction are changes in central nervous system activity (neuropsychiatric and physical stress), causing muscle dysfunction and violation of joint kinematics.
Temporomandibular joint syndrome also develops in patients suffering from depressive disorders. Many people in a state of emotional stress have a spontaneous contraction of the masticatory muscles. Therefore their spasm, incoordination, occlusive disorders, makes trauma to soft tissue and to the joints. Occlusion injury on the background of chronic stressful situations is a direct cause of joint dysfunction.
Symptoms of temporomandibular joint dysfunction syndrome
The classic symptoms of TMJ dysfunction, described by J. Costen, are dull pain in the jaw joint, clicking in the joint during meals, dizziness and headache, pain in the cervical spine, neck and ears, tinnitus and hearing loss, pain in the nose and throat. Currently, the following groups of symptoms are diagnostic criteria for TMJ dysfunction:
1. Sound phenomena in the jaw joint. The most common complaint of patients with temporomandibular joint dysfunction is clicking in the joints that occur when opening the mouth, chewing, yawning. Sometimes it can be so loud that people hear it. In this case, joint pain is not always present. Other noise phenomena may include creaking, crepitation, etc.
2. Blocking (“locking”, “interfering”) of the temporomandibular joint. Uneven movement in the joint when opening the mouth. Namely, in order to open the mouth wide, the patient must first grasp the optimal position of the lower jaw. Patient moves it from one side to the other, finding the place where the joint is “unlocked”.
3. Pain syndrome. When dysfunction of the temporomandibular joint causes pain in the muscles: masticatory, temporal, hypoglossal, cervical, pterygoid, sternocleidomastoid, trapezius muscles. Protopalgia (facial pain), headache, ear pain, toothache, pressure and eye pain are typical. Pain syndrome in TMJ dysfunction can mimic trigeminal neuralgia, cervical osteochondrosis, TMJ arthritis, otitis media and other diseases.
4. Other symptoms. TMJ syndrome may include joint stiffness, dizziness, sleep disturbance, depression, bruxism, dysphagia, xerostomia, glossalgia, paresthesia, photophobia, snoring, sleep apnea, etc.
Prolonged disorder can cause deformities of the affected joint.
Diagnosis of temporomandibular joint dysfunction syndrome
The diagnosis of Costen’s syndrome is complicated by the wide range of external signs that accompany the disease. The difficulty in making a correct diagnosis lies in the fact that due to “wandering” painful sensations, the patient often turns to the wrong doctor for help. The reason for this is that it is difficult to find out where the focus of inflammation is and its cause.
Therefore, patients can go to neurologists, otorhinolaryngologists, general practitioners, rheumatologists and other specialists for a long time before it is discovered that it is Costen’s syndrome. Meanwhile, patients with TMJ syndrome actually need the joint collaboration of dentists and neurologists.
During the initial examination of the patient, the anamnesis is investigated, palpation and auscultation of the joint area are performed, the degree of mouth opening and the mobility of the lower jaw are assessed. In all cases, dentists take jaw imprints to make diagnostic models of the jaw.
It is necessary to assess the condition of the temporomandibular joint, make orthopantomography, ultrasound, X-ray, CT of the temporomandibular joint. Patients should perform an MRI TMJ to detect periarticular soft tissue damage.
Arterial hemodynamic parameters were determined by Doppler or rheoarthrography. Of the functional studies with temporomandibular joint dysfunction, the most important are electromyography (determines the electrical activity of muscles and their overvoltage in relation to the norm), phonoarthrography (assessment of the presence of foreign sounds in the joint) and gnatodynamometry (measures the strength of masticatory jaw function).
TMJ syndrome should be distinguished from subluxations and dislocations of the lower jaw, arthritis and arthrosis of TMJ, fractures of the joint process, synovitis, hemarthrosis, etc.
Treatment of temporomandibular joint dysfunction syndrome
Due to the vague picture of the disease, Costen’s syndrome is more often diagnosed in the later stages of development. This makes treatment difficult.
Most doctors will recommend that people with mild TMJ syndrome use over-the-counter analgesics, massage the painful area, and limited speech and chewing for several days, or rest the jaw by eating soft or liquid foods. More painful or chronic forms of temporomandibular joint syndrome should usually be treated with the help of a dentist, physical therapist, orthodontist, surgeon, or psychologist.
Painkillers can relieve inflammation and pain that accompanies Costen’s syndrome, but do not address the cause of the disease. People with TMJ syndrome should try to see how they can change their lifestyle, from everyday stresses to eating food that burdens the jaw. If the cause of the disease is improper placement of teeth, you should visit a dentist.
During the period of primary treatment, patients with TMJ syndrome must reduce the load on the temporomandibular joint (consuming food of soft consistency, limiting the voice load). Depending on the causes and related disorders in the treatment of TMJ syndrome may involve different specialists: dentists (general practitioners, orthopedists, orthodontists), manual therapists, vertebrologists, osteopaths, neurologists, psychologists.
The treament also includes pharmacotherapy (NSAIDs, antidepressants, sedatives, botulinum therapy, blockades, intra-articular injections of glucocorticosteroids), dosed myogymnastics, massage, physiotherapy (laser therapy, inductothermy, electrophoresis). Important elements of complex therapy can be psychotherapy and BOS therapy, which achieves functional relaxation of the masticatory muscles.
A doctor who suspects that the cause of temporomandibular joint syndrome is excessive muscle stretching may prescribe a muscle relaxant medication such as diazepam to relieve pain and tension. Because temporomandibular joint syndrome can be a chronic disease, a patient should not rely on these prescription drugs for long periods of time. This is because of the dangers of developing an addiction.
In order to reduce the tone of the masticatory muscles, central muscle relaxants (sirdalud, mydocalm), blockade of the motor branches of the trigeminal nerve performed with 2% lidocaine solution are prescribed. To improve muscle metabolism and prevent degenerative-dystrophic processes, Actovegin is injected intravenously, combining injections with topical application of a cream or ointment.
To correct the emotional component of the pain syndrome, patients use antidepressants, sedatives and anxiolytics (afobazole, cipralex, grandaxin). Amitriptyline has a pronounced analgesic effect, pyrazidol normalizes the process of excitation and inhibition. Fevarin has the least side effects.
To eliminate the pain syndrome patients use nonsteroidal anti-inflammatory drugs (voltaren, nimesil, ibuprofen, celebrex). B vitamins together with nicotinic acid reduce pain and improve the metabolism of peripheral nerves during the acute period of the disease.
Stress-related temporomandibular joint syndrome usually responds well to treatment at home. However, if the cause of the pain is an incorrect position of the teeth or an injury to the joint, do not take painkillers regularly. In that case, visit the dentist for an examination.
Dental treatment of temporomandibular joint dysfunction, according to indications, may include measures aimed at re-creating proper tooth closure. For example selective tooth grinding, removal of excessive fillings, competent prosthetics or re-prosthetics, etc.
Some people unconsciously gnash their teeth in their sleep (bruxism). The dentist can diagnose the ailment and give the patient an insert or splint to bite. In some cases, orthopedic and orthodontic treatment of temporomandibular joint dysfunction with fixed devices is approached.
Acupuncture relaxes muscles and thus alleviates the symptoms of stress-induced temporomandibular joint syndrome. As in acupressure, the acupuncturist will treat points on the gastric meridians for stress-related Costen’s syndrome, as these meridians pass through the temporomandibular joints.
In some people with temporomandibular joint syndrome, physical therapy can relieve pain and restore jaw mobility. A physiotherapist may recommend massage, moist and warm compresses, ultrasound, or electric stimulation to improve blood flow and relieve pain and stiffness. To increase the range of jaw movements, the therapist may apply stretching exercises. They also use a technique in which they spray a cooling and numbing fluid over the face and then the patient stretches his jaw muscles. Other possibilities in the application of physical therapy are short-wave diathermy and laser treatment. In these procedures, the waves reach much deeper than moist and warm compresses. The pressure of the waves acts as a massage, increasing blood flow to the affected area and relieving inflammation and pain.
When tension plays a role in temporomandibular joint dysfunction, massage can alleviate it. You can massage two places: one extends from just above and slightly in front of the tip of the ear all the way to the temple. The other is on the jaw about 2.5 cm in front of the ears. Place your finger in one of these places and then open and close the jaw, clenching your teeth slightly. You will feel the muscle bulge and retract as it contracts and relaxes. Place your thumb or forefinger and middle finger on these places and gently massage in small circles. A minute or two of this massage in the places described can help relax the muscles that cause tension around the joint.
For more severe forms of the temporomandibular joint syndrome, consult a physiotherapist and dentist. Techniques that have been found to help are deep massage techniques, neuromuscular massage, rolling and craniosacral work.
Chiropractic is recommended for Costen’s syndrome caused by overuse and muscle strain. It is less helpful with joint injury and in patients who develop jaw joint syndrome after a concussion injury in a car accident. The chiropractor adjusts the patient’s back and body and can apply physical therapy, alternating current, ultrasound or diathermy to the affected joint. all of which help to relax that part of the body and allow the chiropractor to stretch the muscles and adjust the jaw.
A few drops of lavender (Lavandula officinalis) or St. John’s wort (Hypericum perforatum) essential oil in a warm bath can help you relax. To relieve inflammation of the temporomandibular joints, apply warm and cold compresses. First, hold a warm towel for three minutes, then hold a cold towel for half a minute. Repeat this procedure two or three times a day for the chronic form of the disease. For the acute form of the disease repeat it more often.
While relaxation techniques, hypnotherapy, and guided visualization can alleviate the symptoms of TMJ dysfunction syndrome, biofeedback is the most effective way to treat TMJ dysfunction in the field of psychosomatic medicine. Biofeedback does not use drugs, is not invasive, removes tension and allows you to control pain caused by stress. After the course with a professional therapist, you can apply it yourself. By using an electric muscle reader that moves the jaw, the specialist can teach the patient to monitor the tension in that part of the body. Studies have shown that biofeedback is particularly effective in people suffering from the chronic form of Costen’s syndrome. It can help relieve pain and reduce snapping over longer periods of time than other treatments.
For TMJ syndrome sufferers, it is important to reduce the stretching and strain of jaw muscles and joints. Avoid hard foods like fresh carrots and apples and foods that need to be chewed for a long time like steaks and hard pastries. If the jaw pain becomes unbearable, try fasting for a day or two or being on a liquid diet. This method is especially effective if you limit speech to the bare essentials.
In terms of diet, people with TMJ syndrome should take appropriate amounts of bromelain or the bioflavonoid pincogenol in combination with vitamin C to relieve inflammation. Also use calcium and magnesium tablets for muscle cramps, or B vitamins to relieve stress.
In addition to dental surgery, physical therapy, or biofeedback, an osteopath can help you increase the range of motion of your head, neck, shoulders, and upper back with manual techniques. You may be able to find a doctor who specializes in osteopathy and specializes in temporomandibular disorders.
If there is no effect of conservative therapy of TMJ dysfunction, surgical intervention may be required. Such as myotomy of the lateral pterygoid muscle, condylotomy of the head of the mandible, arthroplasty, etc.
Doctors recommend surgery only in exceptional cases. The least invasive form, arthroscopy, is performed by inserting an optical tube through a small incision. The doctors use it to return the disc to its place. If arthroscopy fails, open surgery should be performed on the TMJ. Completely exposing the joint area, and joint replacement may be required. However, before deciding on surgery, the patient must examine all possibilities, possible complications and side effects. He should also seek the second opinion of another experienced surgeon.
Prognosis and prevention of temporomandibular joint dysfunction syndrome
Even without pronounced symptoms and pain, it is necessary to get rid of temporomandibular joint dysfunction. Ignoring this problem leads to serious consequences. For example complete immobilization of the lower jaw, reduction of its functional ability, hearing loss, constant headaches, etc.
To prevent its development, it is desirable to observe the appropriate loads on the chewing apparatus. Also, engage in prosthetics and correct the bite as soon as possible. Even respecting the position and removing bruxism contributes to good predictions.
With timely treatment and adherence to prescribed therapeutic courses, it is possible to talk about long-term treatment, but still successfully. The most difficult and most important thing is to establish the correct diagnosis and start therapy as soon as possible.
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