Temporomandibular Joint Disorder

What is temporomandibular joint disorder?

Temporomandibular joint disorder (TMD -- sometimes referred to as TMJ) is a pain disorder that occurs in the joints of the jaws, on either side of the face. Specifically, it occurs in the joints located in front of the ears, where the lower jaw joins the face. The pain is usually described as a tension-related ache, though in more advanced stages it can be a sharp pain.

The cause of pain is due to orthopedic changes of the jaw, which occurs from persistent wear and tear. The cause of the wear and tear is stress-related clenching and tension of the jaw muscles. It can also sometimes start with a trauma to the jaw joints, which then is combined with stress-related tension in the jaw muscles.

Therapies & procedures for temporomandibular joint disorder

Common treatments for TMD are biofeedback, cognitive behavioral therapies, anti-inflammatory medications, antidepressant medications, bite guards or occlusal adjustments, botox injections, surgical procedures, and chronic pain rehabilitation programs.

Biofeedback

Biofeedback is a method of teaching patients to reduce the chronic jaw muscle tension that leads to TMD. In their meta-analysis, Crider and Glarosdetermined that biofeedback was effective in reducing TMD pain. Indeed, they found that 69% of patients who underwent biofeedback were symptom free after treatment. 

Cognitive behavioral therapies

Cognitive behavioral therapy (CBT) for TMD is a collection of therapies delivered by a health psychologist. CBT essentially teaches patients ways to reduce pain, reduce the emotional distress associated with pain, and reduce the impact that pain has on their lives. In a clinical trial, Litt, et al.,2 randomized 101 men and women into either standard care or standard care with cognitive behavioral therapy. Standard treatment was defined by use of splints, a diet of soft foods, and anti-inflammatory medications. They found that the group with cognitive behavioral therapy had significantly less pain, less depressive symptoms, and less interference in their lives by pain, particularly for those who had a high readiness or motivation for treatment.

Turner, et al.,3 randomly assigned 79 patients with TMD to cognitive behavioral therapy and 79 patients with TMD to a control group who underwent an educational class. At one-year follow-up, patients in the cognitive behavioral therapy group had significantly better improvements on all measures. For examples, half the cognitive behavioral group had at least a 50% improvement in pain. Less than a third of the control group had such improvement. The cognitive behavioral therapy group reported no interference from their TMD at a rate three times higher than the control group.

Anti-inflammatory medications

There are few data that supports the effectiveness of anti-inflammatory medications for TMD pain. Lauren & Dionne4 showed that naproxen reduced pain significantly better than either celecoxib or a placebo.

Antidepressant medications

There is a lack of well-designed research supporting the use of antidepressant medications for the pain of TMD. Their use tends to be supported because of their demonstrated effectiveness with other chronic pain disorders. The only published randomized clinical trial of an antidepressant looked at the use of amitriptyline. Rizatti-Barbosa, et al.,5 found that amitriptyline was significantly better than placebo in reducing pain. However, the trial was very small and the medication was used only for two weeks. Consequently, it is hard to make generalizations to how effective it is in actual clinical practice.

Bite guards or occlusal adjustments

In their Cochrane review, Koh and Robinson6 reviewed 660 published articles on the use of bite guards, only six of which were clinical trials. Upon their review of these six clinical trials, they concluded that bite guards provide no benefit over the comparison or control groups.

In a later meta-analysis of thirteen studies, Zhang, et al.,7 found that occlusal splints were effective for increasing maximal mouth opening and pain.

Botox injections

In a double-blind, placebo-controlled clinical trial for TMD, Nixdorf, et al.,8 found no difference in pain or other measures between patients who were treated with botox injection and those who were treated with a placebo filled injection.

In a later review of studies including non-clinical trials, Chen, at al.,9 found insufficient evidence to show that botox injections are effective.

Surgeries

In their Cochrane review, Rigon, et al.,10 reviewed all published outcome studies on surgery for TMD. They found seven clinical trials. They found that there was no difference in any outcome measure, including pain, between those patients getting surgery and those who did not get surgery.

Chronic pain rehabilitation programs

Chronic pain rehabilitation programs are designed to reduce pain, distress and impairments for patients with any type of chronic pain, including TMD. They are effective in doing so, and there is high quality research evidence demonstrating their effectiveness.11 However, there are no clinical trials assessing the effectiveness of chronic pain rehabilitation programs solely for TMD.

References

1. Crider, A. B., & Glaros, A. G. (1999). A meta-analysis of EMG biofeedback treatment of temporomadibular disorders. Journal of Orofacial Pain, 13, 29-37.

2. Litt, M. D, Shafer, D. M., & Kreutzer, D. L. (2010). Brief cognitive-behavioral treatment of TMD pain: Long-term outcomes and moderators of treatment. Pain, 151,110-116. doi: 10.1016/j.pain.2010.060.030

3. urner, J. A., Mancl, L. & Aaron, L. A. (2006). Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial. Pain, 121, 181-194.

4. Lauren, E. T. & Dionne, R. A. (2004). Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: A randomized placebo-controlled comparison of celecoxib to naproxen. Pain, 111, 13-21.

5. Rizatti-Barbosa, C. M., Nogueira, M. T., de Andrade, E. D., Ambrosano, G. M., & de Barbosa, J. R. (2003). Clinical evaluation of amitriptyline for the control of chronic pain caused by temporomandibular joint disorders. Cranio, 21, 221-225.

6. Koh, H., & Robinson, P. G. (Updated November 12, 2002). Occlusal and adjustment for treating and preventing temporomandibular joint disorders. In Cochrane Database Reviews, 2003, (1). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience.

7. Zhang, C. Wu, J. Y., Deng, D. L., He, B. Y., Tao. Y., Niu. Y. M., & Deng, M. H. (2016). Efficacy of splint therapy for the management of temporomandibular joint disorders: A meta-analysis. Oncotarget. doi: 10.18632/oncotarget.13059

8. Nixdorf, D. R., Heo, G., & Major, P. W. (2002). Randomized controlled trial of botulinum toxin A for chronic myogenous orofacial pain. Pain, 99, 465-473.

9. Chen, Y.-W., Chie, Y.-W., Chen, C.-Y., & Chuang, S.-K. (2015). Botulinum toxin therapy for temporomandibular joint disorders: A systematic review of randomized clinical trials. Oral and Maxillofacial Surgery, 44(8), 1018-1026. doi: http://doi.org/10.1016/j.ljom.2015.04.003

10. Rigon, M., Pereira, L. M., Bortoluzzi, M. C., Loguercio, A. D., Ramos, A. L. & Cardosa, J. R. (Updated April 10, 2010). Arthroscopy for temporomandibular joint disorders. In Cochrane Database Reviews, 2011, (5). Retrieved May 11, 2011, from The Cochrane Library, Wiley Interscience.

11. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

 

Date of publication: November 27, 2016

Date of last modification: November 27, 2016

Murray J. McAllister, PsyD, is the executive director of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides Academic quality information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

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