Temporomandibular dysfunction

Orofacial pain symptoms can appear in a discreet way (in post-operative cases of interventions on the face or in an oncological context) or in a more intense way (Temporomandibular Dysfunction, Neuropathic Pain, Headaches or Migraines).

The most common diagnoses in people with Orofacial Pain include Temporomandibular Dysfunction, Salve Headache, Rhinosinusitis, Migraines, Tension Headaches, Oral Pathology (Burning Mouth Syndrome, Oral Lichen Planus).

The orofacial pain encompasses:

• Temporomandibular Dysfunction
• Pain of the Cervicofacial Masticatory Muscles
• Facial neurovascular pain
• Facial neuropathic pain
• Headaches
• Migraines
• Pain of Oral Origin

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The Temporomandibular Joint

Each person has two temporomandibular joints, one on each side of the jaw. The temporomandibular joint has mainly gliding movements (the only joint in the human body with movements in all three axes), through the contribution of a complex muscular network together with a very particular anatomy.

The temporomandibular joint is divided into bony components (mandibular condyle and temporal fossa), fibrocartilaginous components (articular disc), synovial components (synovial membrane and fluid), and muscular components (cervicofacial muscle chains).

Between the mandibular condyle and the temporal fossa, there is an articular disc. This disc may be displaced (out of place) in some cases of temporomandibular dysfunction.

This displacement of the disc can be responsible for temporomandibular joint pain, difficulty opening the mouth, clicking in the temporomandibular joint, temporomandibular joint blockages.

The Temporomandibular Joint (TMJ) is located in front of the ear and allows you to make essential movements such as chewing, talking, smiling, and even yawning. On average, the temporomandibular joint is moved 2000 times a day.

Normally, you do not notice this joint on a day-to-day basis. When this joint hurts, pops, or limits the normal opening of the mouth, this is when you remember TMJ. When this joint is dysfunctional, we say that there is a TMJ dysfunction (Temporomandibular Dysfunction).

The cervicofacial muscles

The movement of the temporomandibular joint is dependent on the cervicofacial muscles. It is the harmonious relationship between the contraction of some muscle chains and the relaxation of others, in an unconscious way, that allows you to speak, chew, yawn, etc…

Most people with TMJ disorders also have problems with their cervical and facial muscles, why? The answer is simple: whenever you over-contract the muscles of mastication, you are also overloading the temporomandibular joint, thus causing great intra-articular stress.

This stress can be so great that it shifts the disc from its normal position to an abnormal position.

Stress and anxiety are phenomena that contribute to a great muscular overload, especially in the cervical and masticatory muscle chains. Who hasn’t felt their teeth clenching together during stressful moments?

This constant clench-ing of teeth causes prolonged tension in the muscles, which ends up having a negative effect by causing important muscular lesions. These muscle lesions translate into pain, muscle fatigue, tension headaches, and sometimes they can cause tinnitus in some people. It is normal for them to report a grind-like pain, constant throughout the day in the area of the masseters and temporalis.

Causes of temporomandibular dysfunction

In many people, it is difficult to determine exactly what has caused the temporomandibular joint problem. It is known that stress, anxiety, trauma to the temporomandibular joint contribute to an excessive load on the temporomandibular joint which can lead to pain and inflammation of the TMJ.

This overload can displace the disc from its normal position. This displacement of the disc can be associated with pain in the temporomandibular joint, pain that can range from mild to very intense, blockages of the mouth when they are chewing, which can range from mild to severe blockages and/or clicking of the temporomandibular joint.

Signs and symptoms of Temporomandibular Dysfunction

The most frequent symptoms of Temporomandibular Dysfunction are:

  1. Pain at the joint site;
  2. Hearing/feeling cracks when moving the jaw;
  3. Feeling the mouth stuck or blocked;
  4. Difficulty opening the mouth;
  5. Pain in the head (which often spreads to the neck and back);
  6. Feeling sand in the joint;
  7. Tiredness in the chewing muscles.
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Diagnosis of Temporomandibular Dysfunction

Temporomandibular disorders are complex and their origin is multifactorial. To assist in the diagnosis, it is necessary to fill in some symptom-related question-naires, take an adequate clinical history and perform an objective examination.

In the clinical history, you will be asked when you started to feel your complaints, how the disease has evolved, if you have had previous treatments, what level of pain you have felt in the last six months, if you feel your mouth opening has worsened.

You can and should think about it and record the history of your temporomandibular dysfunction in order to help you.

In the objective examination our partners will perform some tests to your joint which together with the medical history and the questionnaires will help in the diagnosis.

After the first consultation, it may be necessary to request

  • MRI scans of the temporomandibular joints and/or;
  • CT scan of the temporomandibular joints and/or;
  • Orthopantomography and/or;
  • Frontal X-ray.

In some situations arthroscopy of the temporomandibular joint can also be used as a mean of diagnosis.

Treatments for Temporomandibular Pain

Non-surgical treatments

Pharmacological treatment

Medication can be prescribed to control the symptoms. The most commonly used drugs are anti-inflammatory, muscle relaxants, antidepressants and antiepileptics.

Conservative non-pharmacological treatment

You may be prescribed with relaxing headgear/plates, auditory biofeedback de-vices, physiotherapy or acupuncture to control your symptoms.

Mesotherapy with toxin type a

A protocol for treating cervical and facial muscles with toxin contributes to long-term results. This protocol allows you to control muscle pain, relax all the muscu-lature and re-educate the cervicofacial muscles.

It not only allows for the relief of pain symptoms, but also allows for an improvement in masticatory function.

Psychotherapy

In specific situations, psychotherapy sessions are recommended.

Surgical treatments

Arthrocentesis of the temporomandibular joint

Arthrocentesis of the temporomandibular joint is a minimally invasive technique, performed most of the time under local anaesthesia.

It’s main objective is to elim-inate the inflammatory mediators responsible for pain, decrease intra-articular pressure, release intra-articular fibrous adhesions and hydrate/lubricate the TMJ.

In the initial phases of temporomandibular joint problems, the disc and the joint are affected by an inflammatory process responsible for the pain. This technique eliminates these inflammatory mediators, thus helping to reduce the pain in this joint.

Joint overload greatly increases intra-articular pressure and this technique allows the overload to be reduced. In very early and particular cases, it allows the disc to be repositioned. In these situations, there is significant dehydration of the disc and joint, which is why a viscous substance (hyaluronic acid) is injected.

This will allow the TMJ and articular disc to be hydrated, thus contributing to a har-monious movement of the temporomandibular joint. All this procedure is done with fine needles so there will be no scar and you can be discharged 30 minutes after the intervention.

Arthroscopy of the temporomandibular joint

Arthroscopy is a technique widely used in medicine. It allows minimally invasive surgical interventions in various joints of the human body such as the temporomandibular joint.

It was Dr. Onishi who first introduced an arthroscope into the Temporomandibular Joint (TMJ) in 1975. This was the beginning of minimally invasive surgery for the treatment of intra-articular TMJ problems.

This technique allows the introduction of a very small camera inside the joint and to make an accurate diagnosis. It also makes it possible to carry out small interventions to reposition the disc, treat areas of chronic intra-articular inflammation, eliminate adhesions from the joint, etc.

There are many high-quality scientific studies recommending arthroscopy for intra-articular treatments, with success rates of over 90% in some series. This technique allows a rapid recovery and leaves a small, practically imperceptible mark on the skin, with the person being discharged 6-8 hours after the intervention.

Open surgery of the temporomandibular joint

Open surgery is reserved for more complex cases. There are various techniques within open surgery that you can discuss with your specialist. Through this approach, a temporomandibular joint prosthesis can be placed.

Other frequent pathologies that cause orofacial pain

Rhinosinusitis

Rhinosinusitis is the inflammation of the nasal cavity and sinuses. People presenting with nasal obstruction, runny nose and changes in smell are likely to have rhinosinusitis as a cause of orofacial pain. The european headache society has validated acute rhinosinusitis as a cause of orofacial pain.

Rhinosinusitis is known to affect about 5-15% of the european population. According to the european position paper on rhinosinusitis and nasal polyps (epos) rhinosinusitis is defined by the presence of 2 or more symptoms, one of which should include nasal congestion/obstruction or anterior/posterior nasal discharge.

Confirmation of the diagnosis requires nasal endoscopy (performed in consultation) or computed tomography (ct) scan of the sinuses.

Thus, rhinosinusitis is unlikely to be the cause of orofacial pain in an individual who does not present with nasal symptoms.

Rhinosinusitis pain

Rhinosinusitis may be acute or chronic if the duration of symptoms is less or more than 12 weeks respectively. If chronic, it is classified into chronic rhinosi-nusitis with nasal polyps and chronic rhinosinusitis without nasal polyps.

Chronic pain

Pain in chronic rhinosinusitis without polyps is very uncommon except in cases of acute onset. In chronic rhinosinusitis with polyps pain is even rarer, and the pre-dominant symptoms in this case are nasal obstruction and absence of smell.

Acute pain

On the contrary, pain in acute rhinosinusitis is usually severe and unilateral, and, in the case of affecting the maxillary sinus, it can also include toothache.

The presence of pain in rhinosinusitis is a cause for concern as the active bacteri-al infection can lead, if left untreated, to complications (orbit abscess, meningitis, brain abscess).

Diagnosis of rhinosinusitis

2 or more symptoms of:

  • Nasal congestion/obstruction;
  • Anterior/posterior nasal discharge;
  • facial pain/pressure;
  • Altered sense of smell.

and the presence of:

  • Changes in nasal endoscopy;
  • Alterations in CT of sinuses.

Tension cephalea

Signs and symptoms

Tension headache is the most common headache in the population, the preva-lence of episodic tension headache is approximately 80%. Due to its high preva-lence, this type of headache is responsible for significant disability and socioeco-nomic impact.

There are two subtypes of tension headache – episodic (most frequent) and chronic.

In episodic tension headache, the most frequent, the headache usually appears in the context of an emotional stress event and is characterised by:

  • Mild to moderate pain;
  • Pain on both sides of the face (bilateral);
  • Pain characterised by tightness or “helmet-like” pain;
  • Pain that does not worsen with daily physical activity;
  • Pain and discomfort may be associated with neck stiffness/ discomfort;
  • Pain lasting from minutes to days;
  • Pain that usually responds to analgesic therapy.

Diagnosis and treatment

Diagnosis

Diagnosis is clinical and depends on clinical history and detailed neurological ex-amination.

Non pharmacological treatment

Regular physical exercise and adequate sleep.

Pharmacological treatment

There is pharmacological treatment aimed at the different cases. Some of the treatments can be carried out with type a toxin.

Migraine

Migraine is a very frequent pathology worldwide. It is more frequent in women (usually in adolescence, peaking in the 3rd decade, then decreasing with advancing age). The onset of migraine after the age of 50 is not very frequent.

Signs and symptoms

Migraine is a neurological illness which manifests itself with episodes of intense and incapacitating headaches.

Clinical Manifestations

There are two main subtypes: migraine without aura (most frequent) and migraine with aura.

Migraine without aura

  • Headache episodes lasting from 4 to 72 hours;
  • Usually unilateral headache;
  • Moderate to severe pain;
  • May have pulsatile sensation;
  • May be aggravated by routine physical activity;
  • May be associated with nausea/vomiting;
  • May be associated with photophobia (phobia of light);
  • May be associated with phonophobia (noise phobia).

Migraine with aura

In this subtype, in addition to the headache episodes with the above mentioned characteristics, people present transient neurological signs/symptoms called aura.

  • typically, these neurological manifestations precede or accompany the headache episode and last for less than 60 minutes;
  • the most frequent aura are visual phenomena which can manifest themselves in different ways but more typically are bright flashes of light, dark mosaic-like spots or bright zigzag images.In other cases, aura can be sensory – changes in sensation on the face or one side of the body, such as tingling or numbness; or it may have involvement of language or muscle strength.

Unlike episodic migraine, chronic migraine is characterised by more than 15 days per month with headache, at least 8 of which must have the above-mentioned features.

Chronic migraine may be associated to secondary headache, associated for example to the abuse of analgesic medication.

Diagnosis and treatment

Diagnosis

The diagnosis of migraine is clinical and therefore depends on a detailed clinical history and neurological examination. A family history is common.

Non pharmacological treatment

In the therapeutic approach, it is important to adopt non pharmacological measures, such as regular physical exercise, weight control and sleep regulation.

The identification of potential precipitating factors is fundamental in order to avoid them when possible. These factors are variable from person to person, there may be more than one in each case and they may vary over time.

Potential migraine precipitating factors:

  • excessive stress;
  • sleep deprivation or excessive hours of sleep;
  • fasting;
  • alcohol;
  • climatic changes;
  • hormonal changes;
  • certain foods: sweeteners, aged cheeses, nitrates, monosodium glutamate, caffeine, among others.

Pharmacological treatment

There is pharmacological treatment aimed at acute migraine episodes and prophylactic treatment that aims to prevent and reduce the intensity and frequency of the episodes.

There are specific drugs for migraine and the most appropriate type of medication should be adapted to each person.

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