TMD presents as a significant clinical problem that affects approximately 12% of the population. (2-4) TMD refers to a complex set of conditions manifested by pain and dysfunction in the region of the face, jaw and head which can limit normal speech, facial expression, eating, swallowing and affect the quality of life both physically and psychologically. Signs and symptoms of TMD include muscle and joint pain, joint crepitus (cracking, popping), functional limitation of jaw opening and headache (HA). Proper management of patients with TMD begins with an extensive history and thorough clinical examination to achieve an accurate diagnosis. Diagnostic classification is difficult because of the multi-system contributions of the sympathetic nervous system, trigeminal nucleus, surrounding pain generators as well as the local system dysfunctions of the TMJ (5).
Literature reports 47-67% of TMD’s are related to myofacial pain disorders of the masticatory muscles, whereas disc disorders are second most common and typically there is a combination of both disc, joint and muscle system dysfunction (2-5). Physical therapists have a primary role in the treatment of patients with TMD as the primary disorders are of musculoskeletal origin.
What I have seen in the clinic in patients with TMJ/TMD: headaches, ear pain, facial pain and difficulty opening mouth all the way. Many people who have TMD present with headaches and are unaware of the involvement and relationship to TMJ. Ear pain is another typical symptom that manifests in TMD. Those with ear pain typically go to Ear Nose Throat (ENT) specialist and find there is no problem with their ear and unfortunately do not seek further options for care. The TMJ is located in the front of the ear. One of the interesting patients I have seen presented with ear pain when wearing her hearing aids. She was evaluated by her ENT and no abnormalities were found. She was fortunately referred to a Physical Therapist with specialty training in TMJ/TMD. These symptoms of HA and ear pain may seem very strange and unrelated to a jaw problem; however, they are the most common symptoms I see in patients without a diagnosis of TMJ/TMD.
Extensive screening is necessary when a pain generator of musculoskeletal origin cannot be found or does not make sense. Possible pain generators can include dental carries/abscess, Trigeminal Neuralgia (TN), sinusitis, temporal arteritis, otitis media, systemic arthropathies and primary HA. The screening of dental carries/abscess can include painful percussion to teeth via tongue depressor, pain when eating sweet, acidic, hot or cold foods and/or red swollen gums and bad breath. In the case of any of these signs patient should be referred to dental professional (7). Trigeminal neuralgia is a diagnosis of exclusion of other clinical features. There are rarely any physical/clinical features, which are prominent in trigeminal neuralgia. There can be sensory loss at V2, V3 and no abnormal reflex or motor function. Trigger points are a main feature of trigeminal neuralgia with sharp shooting pain lasting briefly, 95% present with unilateral symptoms and tic douloureux can be present (8-9). Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses with features including painful palpation to sinus, local swelling and pain that increases with head down and reduces with head up position(9). Temporal arteritis is typically seen in patients >50 y/o, new onset of HA or localized head pain, temporal artery tenderness to palpation, ESR>50 mm/h and acute visual dysfunction (diplopia or acute visual loss). Temporal arteritis is a medical emergency and can result in permanent visual loss without timely ophthalmic referral(9). Otitis media is typical in the pediatric population and features include acute onset of ear pain, middle ear effusion and inflammation(9). Systemic arthropathies can include Lyme disease, gout & pseudogout. Features include elevated ESR, ANA, constitutional signs of malaise, fever, myalgias, arthralgias, neurological symptoms and characteristic rash with Lyme 7-14 days after tic removal(9).
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