Aching Pain In The Face - TMJ

TMJ Syndrome Overview

Temporomandibular joint (TMJ) syndrome is pain in the jaw joint that can be caused by a variety of medical problems. The TMJ connects the lower jaw (mandible) to the skull (temporal bone) in front of the ear. Certain facial muscles control chewing. Problems in this area can cause head and neck pain, facial pain, ear pain, headaches, a jaw that is locked in position or difficult to open, problems biting, and jaw clicking or popping sounds when you bite.

The TMJ is comprised of muscles, blood vessels, nerves, and bones. You have two TMJs, one on each side of your jaw.

Muscles involved in chewing (mastication) also open and close the mouth. The jawbone itself, controlled by the TMJ, has two movements: rotation or hinge action, which is opening and closing of the mouth, and gliding action, a movement that allows the mouth to open wider. The coordination of this action also allows you to talk, chew, and yawn.

If you place your fingers just in front of your ears and open your mouth, you can feel the joint and its movement. When you open your mouth, the rounded ends of the lower jaw (condyles) glide along the joint socket of the temporal bone. The condyles slide back to their original position when you close your mouth. To keep this motion smooth, a soft disc of cartilage lies between the condyle and the temporal bone. This disc absorbs shock to the temporomandibular joint from chewing and other movements. Chewing creates a strong force. This disc distributes the forces of chewing throughout the joint space.

TMJ Syndrome Causes

TMJ syndrome can be caused by trauma, disease, wear and tear due to aging, or habits.

  • Trauma: Trauma is divided into microtrauma and macrotrauma. Microtrauma is internal, such as grinding the teeth (bruxism) and clenching (jaw tightening). This continual hammering on the temporomandibular joint can change the alignment of the teeth. Muscle involvement causes inflammation of the membranes surrounding the joint. Teeth grinding and clenching are habits that may be diagnosed in people who complain of pain in the temporomandibular joint or have facial pain that includes the muscles involved in chewing (myofascial pain). Macrotrauma, such as a punch to the jaw or impact in an accident, can break the jawbone or damage the disc.
  • Bruxism: Teeth grinding as a habit can result in muscle spasm and inflammatory reactions, thus causing the initial pain. Changes in the normal stimuli or height of the teeth, misalignment of the teeth, and changes in the chewing muscles may cause temporomandibular joint changes. Generally, someone who has a habit of grinding his or her teeth will do so mostly during sleep. In some cases, the grinding may be so loud that it disturbs others.
  • Clenching: Someone who clenches continually bites on things while awake. This might be chewing gum, a pen or pencil, or fingernails. The constant pounding on the joint causes the pain. Stress is often blamed for tension in the jaw, leading to a clenched jaw.
  • Osteoarthritis: Like other joints in the body, the jaw joint is prone to undergo arthritic changes. These changes are sometimes caused by breakdown of the joint (degeneration) or normal aging. Degenerative joint disease causes a slow progressive loss of cartilage and formation of new bone at the surface of the joint. Cartilage destruction is a result of several mechanical and biological factors rather than a single entity. Its prevalence increases with repetitive microtrauma or macrotrauma, as well as with normal aging. Immunologic and inflammatory diseases contribute to the progress of the disease.
  • Rheumatoid arthritis: Rheumatoid arthritis causes inflammation in joints and can affect the TMJ, especially in children. As it progresses, the disease can cause destruction of cartilage and erode bone, deforming joints. It is an autoimmune disease involving the antibody factor against immunoglobulin G (IgG). Chronic rheumatoid arthritis is a multisystem inflammatory disorder with persistent symmetric joint inflammation.

TMJ Syndrome Symptoms and Signs

  • Pain in the facial muscles and jaw joints may radiate to the neck or shoulders. Joints may be overstretched. You may experience muscle spasms from TMJ syndrome. You may feel pain every time you talk, chew, or yawn. Pain usually appears in the joint itself, in front of the ear, but it may move elsewhere in the skull, face, or jaw.
  • TMJ syndrome may cause ear pain, ringing in the ears (tinnitus), and hearing loss. Sometimes people mistake TMJ pain for an ear problem, such as an ear infection, when the ear is not the problem at all.
  • When the joints move, you may hear sounds, such as clicking, grating, and/or popping. Others may also be able to hear the sounds. Clicking and popping are common. This means the disc may be in an abnormal position. Sometimes no treatment is needed if the sounds give you no pain.
  • Your face and mouth may swell on the affected side.
  • The jaw may lock wide open (then it is dislocated), or it may not open fully at all. Also, upon opening, the lower jaw may deviate to one side. You may find yourself favoring one painful side or the other by opening your jaw awkwardly. These changes could be sudden. Your teeth may not fit properly together, and your bite may feel odd.
  • You may have trouble swallowing because of the muscle spasms.
  • Headache and dizziness may be caused by TMJ syndrome. You may feel nauseous or vomit.

When to Seek Medical Care

Occasional pain in the jaw joint or chewing muscles is common and may not be a cause for concern. See a doctor if your pain is severe or if it does not go away. Treatment for TMJ syndrome ideally should begin when it is in early stages. The doctor can explain the functioning of the joints and how to avoid any action or habit (such as chewing gum) that might aggravate the joint or facial pain.

If your jaw is locked open or closed, go to a hospital`s emergency department.

  • The open locked jaw is treated by sedating you to a comfortable level. Then the mandible is held with the thumbs while the lower jaw is pushed downward, forward, and backward.
  • The closed locked jaw is treated by sedating you until you are completely relaxed. Then the mandible is gently manipulated until the mouth opens.

Exams and Tests

  • Medical history: In diagnosing your jaw problem, the doctor will ask the following questions:
    • What kind of pain do you have?
    • Is it an ache or a throbbing pain or a sharp stabbing pain?
    • Is the pain continuous or intermittent?
    • Can you outline the area of pain on your face with your finger?
    • What helps to alleviate the pain? What aggravates the pain?
    • Do you grind or clench your teeth? Do you bite your nails or chew on any objects, such as pens or pencils?
    • Do you hold the telephone with your shoulder against your ear for a long time?
    • Do you chew gum often? For how long?
    • Do you have any oral habits that you have not mentioned?
  • Physical examination: During the physical examination, the doctor will examine your head, neck, face, and temporomandibular joints, noting any of the following:
    • tenderness (pain) and its location;
    • sounds, such as clicking, popping, grating;
    • the mandible (lower jaw) range of motion and whether it is easy to open and close and can move from side to side and forward-backward without any pain;
    • your assessment of pain on a scale from 0 (no pain) to 10;
    • wear and tear on the buccal cusps of the mandibular teeth, especially the canine teeth;
    • the rigidity and or tenderness of the chewing muscles;
    • how your teeth fit together: normal, open bite, crossbite, overbite, dental restorations, or skeletal deformity.
  • Imaging: X-rays may be taken of the mouth and jaw. CT or MRI may also be used. The MRI was designed for imaging of soft tissue and, therefore, will show the location of the TMJ disc in relationship to the jaw and skull bones. That will give the doctor a better idea as to the proper treatment approach.

TMJ Syndrome Treatment

Self-Care at Home

Many people, more women than men, have TMJ syndrome. However, the full TMJ disorder develops in only a few. Most of the symptoms disappear in two weeks because your jaw joint rests and recovers when you are unable to chew.

  • Anti-inflammatory pain medications
  • Eat a diet of soft foods.
  • Apply warm compresses on the area of pain. Home therapy includes mandible (lower jaw) movements, such as opening and closing the jaw from side to side. Try this after a warm compress is applied for 20 minutes. The lower jaw movements should be repeated three to five times a day, five minutes continuous

Medical Treatment

Most cases of TMJ syndrome are temporary; thus, treatment is usually conservative.

  • Early therapy starts simply with resting the jaw, using warm compresses (ice packs at first if an injury is present), and pain medication. Jaw rest can help heal temporomandibular joints. Eat soft foods. Avoid chewing gum and eating hard candy or chewy foods. Do not open your mouth wide. Your doctor may show you how to perform gentle muscle stretching and relaxation exercises. Stress-reduction techniques may help you manage stress and relax your jaw along with the rest of your body.
  • The doctor may fit you with a splint or bite plate. This is a plastic guard that fits over your upper and lower teeth, much like a mouth guard in sports. The splint can help reduce clenching and teeth grinding, especially if worn at night. This will ease muscle tension. The splint should not cause or increase your pain. If it does, do not use it.
  • If conservative and noninvasive techniques do not work, you may consider more invasive techniques.
  • A more invasive procedure can be performed in the doctor`s office or clinic under local anesthesia. This is carried out by inserting two needles in the temporomandibular joint to wash it out. One needle is connected to a syringe filled with a cleansing solution, and the fluid exits via the other syringe. This procedure can be done in the office. Most people find relief from the pain and return to almost normal. Sometimes, pain medication can be injected into the joint in a similar procedure.
  • Alternatively, a simple injection of cortisone medication can be very helpful in relieving inflammation and pain.
  • A last option, surgery, is often irreversible and should be avoided when possible. If necessary, surgery can be used to replace the jaw joints with artificial implants. The National Institute of Dental and Craniofacial Research (NIDCR) advises that if surgery is recommended, you seek other independent opinions before proceeding.
  • NIDCR advises that other irreversible treatments are of little value and may not cure the problem. These include orthodontia to change the bite, restorative dentistry, and adjustment of the bite by grinding down teeth to bring the bite into balance.

Follow-up

Follow your doctor`s specific instructions for taking any medication prescribed and for home care with compresses or gentle jaw exercise.

  • You may be instructed to follow up with a specialist such as an oral and maxillofacial surgeon, a general dentist, or a pain specialist physician. Maxillofacial surgery may be necessary when there is poor alignment of the jaw bone (mandible) with the skull bone.
  • Dentists are often the first to diagnose TMJ syndrome. They are familiar with conservative treatments. Specially trained facial pain experts can be helpful in diagnosing and treating TMJ syndrome.

Prevention

  • If you tend to have occasional bouts with jaw pain, avoid chewing gum or biting on objects, such as pens or fingernails. Avoid eating hard or chewy food. When you yawn, support your lower jaw with your hand.
  • See your dentist if you grind your teeth at night or find yourself clenching your jaw. The dentist can make a splint for you.

Outlook

Most people do well with conservative therapy, such as resting the jaw or using a mouth splint. The success of treatment depends on how severe the symptoms are and how well you comply with treatment.

  • Only about 1% of those with TMJ syndrome require joint replacement surgery.

Multimedia

  • Temporomandibular joint (TMJ) syndrome.
    The mandible (jawbone).

  • Temporomandibular joint (TMJ) syndrome.
    The mandible (jawbone) and its placement to the skull at the TMJ.

  • Temporomandibular joint (TMJ) syndrome.
    MRI showing TMJ internal derangement.

  • Temporomandibular joint (TMJ) syndrome.
    Problem with teeth worn down, caused by grinding (bruxism).

  • Temporomandibular joint (TMJ) syndrome.
    Jaw in closed lock position.

  • Temporomandibular joint (TMJ) syndrome.
    Same person as in image 5, after relieving the closed lock joint.

  • Temporomandibular joint (TMJ) syndrome.
    Joint sideways.

  • Temporomandibular joint (TMJ) syndrome.
    Open lock.

  • Temporomandibular joint (TMJ) syndrome.
    After open lock reduction.

  • Temporomandibular joint (TMJ) syndrome.
    Closed lock mandible.

  • Temporomandibular joint (TMJ) syndrome.
    Two needles in place to start the procedure.

  • Temporomandibular joint (TMJ) syndrome.
    The surgeon cleaning (lavaging) the temporomandibular joint.

  • Temporomandibular joint (TMJ) syndrome.
    Image showing artificial TMJ replacement.

  • Temporomandibular joint (TMJ) syndrome.
    Physical therapy using the fingers.

  • Temporomandibular joint (TMJ) syndrome.
    Physical therapy with tongue depressors.

Authors and Editors

Author: William C Shiel Jr. , MD, FACP, FACR
Editor: Melissa Conrad Stoppler, MD. Chief medical editor: Emedicinehealth.com

Previous contributing authors and editors:

Emedicinehealth.com
Author: Hamed Hassan Ali Al-bargi, DMD, Staff Physician, Department of Oral and Maxillofacial Surgery, Thomas Jefferson University Hospital.
Coauthor(s): Zainab Hassan Al-abbasi, BDS, AGED, Consulting Staff, Dental Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia; Paul D Streck Jr, MD, DMD, MBA, Assistant Professor of Oral and Maxillofacial Surgery, Thomas Jefferson University; Associate Director, Department of Surgery, Thomas Jefferson University Hospital; Robert J Diecidue, MD, DMD, MBA, Assistant Professor of Oral and Maxillofacial Surgery, Thomas Jefferson University; Chair and Program Director, Department of Oral and Maxillofacial Surgery and Dentistry, Thomas Jefferson University Hospital.
Editors: James E Keany, MD, FACEP, Director of Emergency Medical Education, Department of Emergency Medicine, Mission Hospital Regional Medical Center and Children`s Hospital at Miss; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James Ungar, MD, Medical Director, Chair Department of Emergency Medicine Santa Rosa Memorial Hospital.

REFERENCE:

Koopman, William, et al., eds. Clinical Primer of Rheumatology. Philadelphia: Lippincott Williams & Wilkins, 2003.