Temporomandibular Joint Injury

By admin On Nov 7, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Daniel Lewis

Basics

Temporomandibular joint (TMJ) injuries, while relatively uncommon, do occur in sport. Players in collision sports (eg, football, field hockey, soccer, lacrosse) may be at particular risk, along with divers.

Description

The cause of TMJ pain dysfunction syndrome (TMPDS) is unclear in most patients.
May be related to an abnormality in neuromuscular mechanics: Trauma, dentoskeletal malocclusion, and bruxism are important contributors.
Up to 70% of sufferers may have displacement of the articular disk, made up of fibrocartilage.
Osteoarthrosis is another common cause of TMJ pain.
May be related to whiplash injuries or related acceleration-deceleration injuries in sport

Epidemiology

Incidence

10–20 million adults suffer TMPDS (up to 3–7% of the adult population may seek treatment at some point in their lives).
Patients typically present in 4th decade of life, unless problem is related to injury. ∼1/3 of TMPDS sufferers report a previous history of macrotrauma.
Predominant gender: Female > Male (2:1, although this ratio may be reversed in athletes)

General Prevention

Use of mouth guards in sport may provide protection against traumatic causes.
Proper technique in sports-specific activitis
Avoidance of repetitive or unilateral chewing

Commonly Associated Conditions

In cases of trauma, other facial injuries may be related:

Mandibular or other orofacial fractures
Cervical neck injury may occur in whiplash-type injuries.

Diagnosis

Diagnosis based on clinical presentation
Exclude other causes of unilateral facial or head pain

History

History of pain with chewing, particularly repetitive chewing
May have related history of trauma

Physical Exam

Dull, aching unilateral jaw, ear, or head pain: Exacerbated by opening the mouth
A “popping” or “clicking” sensation may be noted with chewing.
Limited range of motion of the mandible
Symptoms more conspicuous in the evening and less prominent on awakening
Pain may refer to a variety of locations on the ipsilateral hemicranium and supraclavicular region.
Dentoskeletal malocclusion
Mandibular deviation with opening and closing of the mouth
TMJ capsule tenderness
Tenderness over the muscles of mastication
A palpable click often can be palpated with opening and closing of the mouth.

Diagnostic Tests & Interpretation

Plain radiographs are of little value.
Tomograms, bone scintigraphy, CT scan, and MRI are not necessary during the initial evaluation of TMPDS in the ED.

Lab

No specific laboratory tests are indicated.

Imaging

Not necessary for diagnosis; may be helpful to rule out other disorders with similar symptoms

Differential Diagnosis

Mandibular fracture
Myocardial ischemia
Carotid or vertebral artery dissection
Intracranial hemorrhage (subarachnoid hemorrhage)
Temporal arteritis
MS may present with pain similar to trigeminal neuralgia.
Trigeminal or glossopharyngeal neuralgia
Vascular headache
Dental abnormalities
Herpes zoster
Salivary gland disorder, otitis media, external otitis, and sinusitis
Elongated styloid process pain often is precipitated by swallowing or turning the head.

Treatment

Typically treated as outpatients with pain medication, muscle relaxants, and warm compresses
In general, symptoms from acute injury resolve within 7–10 days, although a significant percentage of patients may have long-term sequelae.

Pre-Hospital

Evaluate patient to rule out other more serious injuries:
- Cervical spine injuries
- Orofacial fractures
In acute injuries, conservative measures are applied:
- Protection from further injury
- Icing
- NSAIDs for pain relief if indicated
- Decreased stimulation (ie, chewing) on affected side

P.575

ED Treatment

Pain control
Radiographs to rule out other injuries as clinically indicated (plain film, CT)
Refer to dentist or oral-maxillofacial surgeon for occlusal splints.

Medication

Oral or parenteral analgesics (NSAIDs, occasionally narcotics)
Muscle relaxants
Additional adjunct therapies:
- Tricyclic antidepressants
- Intra-articular and local injections of anesthetics or steroids
- Hyaluronic acid injection has not been widely studied.

Additional Treatment

Vapocoolant spray with physiotherapy
Warm/cold compresses
Behavior modification
Physical therapy exercises to strengthen muscles of mastication, maintain range of motion
US or massage also may be beneficial.
While not studied extensively, a mouthpiece or mouthguard may help to relieve some postinjury pain.

Referral

Pain or loss of function uncontrolled by the preceding may benefit from referral to maxillofacial or orofacial surgeons.
Surgery is rarely required, but may consist of:
- Arthrocentesis and arthroscopy
- Hemiarthroplasty
- Osteotomy
- Total joint replacement is considered a salvage procedure.

In-Patient Considerations

Initial Stabilization

N/A

Ongoing Care

Diet

A soft diet may be effective in reducing pain severity during episodes.
Chewing gum also may make symptoms worse.

Prognosis

Typically self-limited but can progress to a chronic state of inflammation and pain

Additional Reading

Marbach JJ. Tempomandibular pain dysfunction syndrome: history, physical examination and Treatment. Rheum Dis Clin North Am. 1996;22:47–98.

Marbach JJ. Temporomandibular pain and dysfunction syndrome. History, physical examination, and treatment. Rheum Dis Clin North Am. 1996;22:477–498.

Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008;87:296–307.

Codes

ICD9

524.60 Temporomandibular joint disorders, unspecified
848.1 Jaw sprain
959.09 Other and unspecified injury to face and neck