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J West Afr Coll Surg. 2016 Jan-Mar; 6(1): 70–87.
PMCID: PMC5342624

TEMPOROMANDIBULAR PAIN DYSFUNCTION SYNDROME IN PATIENTS ATTENDING LAGOS UNIVERSITY TEACHING HOSPITAL, LAGOS, NIGERIA

Abstract

Background

Temporomandibular joint pain dysfunction syndrome (TMJPDS) is the most common temporomandibular disorder. This condition presents with symptoms of pain, restricted jaw movement and joint noise. Other symptoms include otalgia, headache, neck pain and trismus.

Aim

To determine the pattern of Temporomandibular joint pain dysfunction syndrome patients managed at the Lagos University Teaching Hospital, Lagos, Nigeria.

Methodology

A descriptive study of patients with signs and symptoms of Temporomandibular joint pain dysfunction syndrome attending the Oral Medicine Clinic of Lagos University Teaching Hospital.

Results

Twenty-one patients with Temporomandibular joint pain dysfunction syndrome were enrolled into the study, out of which 10(48%) were females and 11(52%) were males. The age range was 23-81years with a mean of 45.2 ± 18.9 years. Majority of the patients 20(95.2%) complained of pain around the joint, in the pre-auricular region, in the muscles of mastication and the ear. While 7(35%) complained of clicking sounds, 10(47.6%) complained of pain on mouth opening and during mastication only. In all 5(23.8%) had impaired movement of the jaws, mouth opening was normal in 18(85.7%) but reduced in 3(14.3%) patients. Over half of patients 12(57%) experienced clicking sounds, there was tenderness around the temporomandibular joint in 16(76.2%) cases, pain in the ear of 7(33.3%) patients and 13(61.9%) people presented with tenderness of the muscles of mastication. Conservative management of all the cases resulted in resolution of the symptoms.

Conclusion

Temporomandibular joint pain dysfunction syndrome has diverse clinical presentation and though distressing, it responds to prompt and effective conservative management.

Keywords: Temporomandibular joint pain dysfunction syndrome, Diverse presentation, Conservative management, Good outcome

Introduction

The temporomandibular joint (TMJ) is formed by the head of mandibular condyle and the glenoid fossa of the temporal bone. The space between these two bony structures is occupied by a fibro-cartilagenous disc which has ligamentous attachments to both the mandibular fossa and condyle. The articular disc's attachments create separate superior and inferior joint compartments, while the disc itself provides an interface for the condyle as it glides across the temporal bone. The joint ligament permits rotational movement of the disc on the condyle during mouth opening and closing. Thus, the TMJ is capable of both hinge-type movement and gliding movement. Loss of normal functions of the joint like mastication and speech in association with pain is characteristic of masticatory systemic disorders of which temporomandibular joint pain dysfunction syndrome (TMJPDS) is one. This condition causes significant distress that can be severely disabling to the patient1.

Temporomandibular joint pain dysfunction syndrome otherwise known as facial arthromyalgia, TMJ dysfunction syndrome, myofacial pain dysfunction syndrome (MPD), craniomandibular dysfunction and Costen's syndrome2 is the most common temporomandibular disorder as it affects up to 30% of individuals3. It is characterized by the appearance of pain, joint sounds and alterations in mandibular movement4. TMJPDS is a musculoskeletal pain condition affecting the TMJ, masticatory muscles, and/or associated structures. It is a collective term that describes all the medical conditions related to the TMJ and its musculoskeletal structures. This disorder shares the symptoms of pain, limited mouth opening and joint noises/clicks - these are the three cardinal symptoms of TMJ disorders. Other TMJ disorders include TMJ arthritis, ankylosis, dislocation, and so on.

TMJPDS is a pain disorder characterized by spontaneous pain and jaw function-induced pain in the joint and muscles of mastication of the TMJ because of the interplay between the muscles and joints, a problem with either one can lead to stiffness, headaches, ear pain, malocclusion, clicking sounds, or trismus. It is a common but misunderstood muscular pain disorder involving pain referred from small, tender trigger points within myofascial structures in or distant from the area of pain5. The disorder and the resultant dysfunction can result in significant pain and impairment.

The aetiology of TMJPDS is known to include; tension, fatigue or spasm in the masticatory muscles, bruxism which increase the tear and wear on the cartilage lining of the TMJ, habitual gum chewing or fingernail biting, malocclusion, trauma to the jaws , stress, occupational tasks such as holding the telephone between the head and shoulder, chewing and yawning6.

Although the definitive pathogenesis of TMJPDS is currently unknown, and no single diagnostic method is consistently positive7, it is commonly a stress-induced psycho-physiologic disease originating in the muscles of mastication and not an organic disease arising in the temporomandibular joint8,9.

Several symptoms have been associated with TMJ disorders in patients presenting with TMJ dysfunction syndrome and these includes pain, biting or chewing difficulty or discomfort, clicking, popping or grating sound when opening or closing the mouth, dull ache in the face, earache, headache, jaw pain or tenderness of the jaw, reduced ability to open or close the mouth, neck pain. The principal findings are tenderness of the TMJ and associated muscles of mastication, trismus, limited or jerky jaw movements, and evidence of bruxism (tooth wear). There could also be frictional keratosis of the buccal mucosa and the tongue, signs of internal derangement of the TMJ (subluxation) include clicking noises and lateral displacement of the meniscus10.

Between 65 - 85% of people in the United States experience some symptoms of TMJPDS during their lives, and approximately 12% experience prolonged pain or disability that results in chronic symptoms. Although the prevalence of one or more signs of mandibular pain and dysfunction is high in the population, only about 5 - 7% have symptoms severe enough to need treatment4,11,12. A Nigerian study reported that a total of 62.8% of their subjects exhibited varying degrees of symptoms and signs of temporomandibular disorders13. Other researchers in our environment have noted TMJPDS as the most common cause of oro-facial pain after odontalgia14,15.

Diagnosis of TMJPDS is based on history and clinical examination, although radiography, arthroscopy, and magnetic resonance imaging are routinely used in advanced centers for investigation, none of these methods have been evaluated for their sensitivity and specificity16.

The American Dental Association recommends the use of analgesics, muscle relaxants and relaxation therapies, anxiolytics, heat therapy, simple muscular exercises, habit modification and use of bite splinting in patients with the pain disorder17. Randomized controlled trials to evaluate surgical interventions are required before they are recommended. Since more studies are needed on the safety and effectiveness of most treatments for jaw joint and muscle disorders, experts recommend the most conservative, reversible treatments possible. Conservative treatments do not invade the tissues of the face, jaw, or joint, or involve surgery. Reversible treatments do not cause permanent changes in the structure or position of the jaw or teeth. Even when TMJ disorders have become persistent, most patients still do not need aggressive types of treatment18,19.

Misdiagnosis or inadequate management of this disorder after onset may lead to development of a complex chronic pain syndrome.

The current study therefore aims to report our experience with managing TMJPDS at Lagos University Teaching Hospital, Lagos, Nigeria over a period of 3 years.

Materials and methods

A cross sectional retrospective study was carried out in patients with signs and symptoms of Temporomandibular joint pain dysfunction syndrome attending the Oral Medicine Clinic of the Department of Preventive Dentistry of the LUTH, Lagos from January 2011 to December 2014.

A total of 21 patients with clinical features consistent with TMJPDS were enrolled. The data collected included the socio-demographics, clinical features, management options and outcome. Attention was paid to the presence of jaw pain during mastication, joint swelling, parafunctional habits, (teeth grinding, thumb or lip sucking, chewing gum habits) and sleep patterns. Presence of other symptoms such as; fever, headaches, locked jaw (trismus), clicking or gritting sound, and difficulty in mouth opening were all noted, as they could also be related symptoms of TMJPDS.

Subjects were examined for pain and other related joint symptoms such as, clicking/crepitations, locking, luxation); pain on jaw movement, muscle pain, pain on palpation at rest/ during movement.

All the patients were treated symptomatically by the use of analgesics, muscle relaxants, anxiolytics drugs and in some cases heat therapy administered by a physiotherapist.

The data obtained were analyzed for means and frequencies using the EPI Info Statistical Software, version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA).

Results

Out of the 21 patients in this study, 11(52%) were males while 10(48%) were females, with a male to female ratio of 1.08:1 and their age ranged between 23-81years, with a mean age of 45.2 ± 18.9 years. Majority of the patients 7(33.3%) were in the age group 21-30years, followed by 4(19.1%) in the age group 51-60years and the least affected age group 1(4.8%) was age 81-90years bracket. Table 1 shows the age distribution of the patients.

In all, 20(95.2%) of the patients complained of pain around the joint, pre-auricular region, muscles of mastication and the ear region, 7(35%) complained of clicking sounds, while 10(50%) complained of pain on opening the mouth during mastication. Most 13(61.9%) of the patients did not have any para-functional habits, while 8(38.1%) had habits such as clenching, grinding of teeth and consistent chewing of gum. Table 2 shows the clinical features of the patients.

While 5(23.8%) patients had impaired movement of the jaws, mouth opening was normal in 18(85.7%) and reduced in 3(14.3%). In 12(57%) cases clicking sounds were elicited, with crepitus in 1(4.8%) patient. There was tenderness around the TMJ in 16(76.2%) patients, pain in the ear of 7(33.3%) and tenderness of the muscles of mastication in 13(61.9%) patients. Bilateral pain was seen in 9(45%) patients, while 10(50%) patients had unilateral pain. Deviation of the mandible on closing was observed in 4(19%) patients, 6(28.6%) cases presented with malocclusion, whereas 15(71.4%) had no form of malocclusion. Although severe molar attrition was seen in 4(19%) of the cases, 8(38.1%) patients had missing teeth greater than 4.

All the patients in this study received conservative treatment. Most of our patients (74%) were treated by a combination of; soft diet, analgesics, use of muscle relaxants, anxiolytics drugs and heat therapy via infra-red light machine administered by a physiotherapist. Some others (24%) had treatment with muscle relaxant alone and only 1(4.8%) patient was treated with the use of cap-splint because of chronic bruxism. Table 4 shows the treatment modalities in this study. There was 1(4.8%) case of recurrence.

Discussion

Temporomandibular joint pain dysfunction syndrome is a group of symptoms characterized by pain, clicking, difficulty with mouth opening and mastication. This study showed an almost equal predilection of symptoms in both males and females which is contrary to the study that showed a clear female predilection20 and another study in Nigeria that showed male predominance15. As this is a preliminary study, the relatively smaller number of study subjects may be a factor for the almost equal gender predilection.

In our series; majority of the patients were below the age of 40 years, with most patients (33.3%) between 21-30 years age group. The incidence of pain seen in young adults in the present study is in accordance with the theory that TMJPDS is more prevalent in early adulthood21.

A review of the clinical characteristics of 164 patients in United States of America whose chief complaints led to the diagnosis of TMJPDS had tenderness at points in firm bands of skeletal muscle that were consistent with past reports, specific patterns of pain referral associated with each trigger point, frequent emotional, postural, and behavioral contributing factors, and frequent associated symptoms and concomitant diagnoses5.

Pain was the most common presenting complaint as majority (95.2%) of the patients presented with pain - a finding consistent with past studies22,23,24. TMJPDS in this study was characterized clinically by pain in the joint and the masticatory muscles. The pain was a result of the pathological contraction of the masticatory muscles which stimulated extravascular production of inflammation-associated substances around the joint25.

Limited mouth opening and clicking sounds in the ear are also common features seen in these patients; the presence of these two symptoms is consistent with findings by other workers21,26.

About 38.1% of the patients had a para-functional habit which could be attributed to an aetiological factor, while others could not relate the onset of symptoms to any known aetiological factor; this is consistent with a study done in Brazil among adolescent patients in 201327. Over a third (38%) of our patients had more than 4 missing posterior teeth, severe attrition of teeth and malocclusion which further potentiated the condition. Psychosomatic causes especially the role of stress was not ascertained in this group of patients.

All the patients in this study were treated conservatively with the use of analgesics, anxiolytics, muscle relaxants and heat therapy as recommended by other researchers elsewhere with good outcome15. Each patient was however treated based on the unique symptoms at presentation, the pattern of presentation and other contributing factors. Treatment outcome for all the patients was favourable with the presenting symptoms abating within one to three weeks of intervention. The success rate after treatment is in line with other studies18,19,28.

The limitation of this study was the small sample size and the retrospective nature of the study.

Conclusions

Temporomandibular joint pain dysfunction syndrome has diverse clinical presentation and though distressing, it responds to prompt and effective conservative management.

Table 1
Age distribution of the patients
Table 2
Clinical features of the patients
Table 3
Clinical signs of the patients
Table 4
Treatment modalities

Footnotes

Competing Interests: The authors have declared that no competing interests exist.

Grant support: None

References

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