---

Temporomandibular Joint Disorders (TMJD) - T2.1

Definition of condition: TMJD is a collective term comprising a number of clinical problems that involve the masticatory musculature, the TMJ, or both.

Issue statement: It is recognized that the TMJ can sustain injury as a result of work related trauma.  Many TMJ injuries are associated with non-work related disorders.  The TMJ is a synovial joint that is subject to the same pathological conditions that affect other joints in the body.  Therefore, before a claim is accepted, a thorough medical history, dental history, and pre-existing TMJ status assessment must be obtained, as well as a non-occupational (e.g. recreational/hobby/leisure) and occupational history.

WCB-Alberta position

Work relationship criteria

Work relationship may be considered if one or more of the following criteria are present:

• the worker sustains a traumatic injury such as whiplash injury, fall, knock, or blow etc. to the head, neck or TMJ area (see whiplash guideline)
• damage to the TMJ resulting from iatrogenic sources such as intubation for the administration of general anesthesia, difficult dental treatment (i.e. broken tooth removal or other prolonged dental procedures) if the treatment was required because of a compensable injury
• Secondary to clenching/bruxism related to WCB accepted claims for emotional stress such as Post Traumatic Stress Disorder

In reference to traumatic injuries and/or iatrogenic injury, TMJ symptoms should manifest within 3 months of incident.

Clinical criteria

TMJD are characterized by the following:

Early manifestations:

• headaches (temporal, parietal and frontal), pain in and around the TMJ such as jaw or ear tenderness, neck ache, deviation of the jaw during opening and closing movements.  Limited head, neck and jaw movements, vertigo, loss of equilibrium, tinnitus may also occur with any or all of the above.

Early or late manifestations:

• abnormal bite, difficulty chewing and swallowing, TMJ stiffness, TMJ noise and sore teeth.

Recommended procedures by a designated specialist:

• examine mandibular ROM and note joint noise; assess response to muscle and joint palpation
• examine head and neck for abnormalities such as muscle spasm, movement disorders, systemic disease, and trigger points
• intraoral exam
• otoscopic exam

Optional:

• psychological studies, particularly if symptoms are prolonged (> 6 months) despite splint treatment and definitely pre-surgery
• neuro consult if cranial nerve sensory deficits, facial weakness, numbness etc. are present

Diagnostic criteria

Recommended imaging:

• panoramic film or tomogram (if history of recent trauma, painful clicking or advanced degenerative joint disease is suspected)
• CT if suspicious of a fracture or tumor 

Optional:

• MRI if difficult/unusual diagnosis 
• arthrography (invasive - usually reserved for use as a presurgical diagnostic aid)

Recommend against:

• CT  for evaluation of internal derangement
• scintigraphy, electronic thermography  (little diagnostic or management value)

Recommended management

Management should focus on patient education, decreasing pain, reducing or eliminating the effects of adverse loading and restoring or maintaining normal function of the TMJ.

Education

It is vital  that the worker understands that he/she plays the most important role towards recovery.

Recommend education:

• home care instruction should include: rest the masticatory system, habit awareness and modification

Optional:

• behavior modification: eliminate habits such as teeth grinding, clenching, nail biting;
  encourage eating of softer foods, taking smaller bites, and slower chewing
• psychological assessment, stress management and cognitive awareness training or biofeedback if indicated

Recommend against:

• hard & sticky foods
• tearing foods with front teeth
• hobbies  that require use of jaw i.e., mouthpiece used for scuba diving, snorkeling etc
• supporting phone against shoulder with chin or propping up chin with one hand

Physical methods of treatment

Dental and Physical  therapy are widely regarded as the leading treatment for TMJD.

Dental therapy

• treatment with intraoral appliance if  painful TMJ derangement or bruxism
• oral splints/orthotics; if no improvement after 3 to 4 weeks, re-evaluate effectiveness of appliance; discontinue use of 24 hour splints after 3 months; assess WCB responsibility for continued use of night-time splinting after 1 year.
• refer to physio for TENS and/or biofeedback

Physical therapy

Recommended physio:

• at home program for 6 weeks
• continuous passive ROM during inflammatory stages (special equipment needed)
• treatment of neck pathology

Optional:

• ultrasound or laser therapy 3 times per week for 10 - 12 treatments
• heat, massage, ice,
• if limited ROM, strengthening exercises & stretching
• biofeedback &/or TENS

Recommend against:

• avoid intense isometric exercises when rebuilding strength (can aggravate condition)

Medical treatment

Drugs

Most pharmacological agents are intended to relieve pain, reduce muscle spasm, or to lower psychic tension.

Optional pharmacotherapy:  The table below lists some of the more common drug types  used, however the majority of the literature does not provide specific duration recommendations.

Agent:	Acute/short term duration	Chronic/long term duration
NSAIDs:	-up to 8 weeks max., then reassess	-only on reassessment may be used recurrently
Mild analgesia (non-narcotic)	- as required	-as required
Skeletal muscle relaxants	- up to 2-3 weeks max.	- not recommended
Antianxiety &/  minor tranquilizers	- as required	- not recommended
Antidepressants:	- not recommended	- minimum of 3-6 months
Anesthetic injection with or without cortisone:	- not recommended

Note: Most epidemiologic studies show a 60% to 80% success rate after conservative treatment alone; drug therapy is not the main treatment for chronic TMJD.  It is only an adjunctive therapy and should be eliminated or reduced as soon as possible

Recommend against:

• narcotic analgesia

Occlusion correction

Occlusion correction may be needed as a result of a fracture from a compensable trauma.  Treatment of a pre-existing malocclusion is also sometimes required to resolve a work-related injury and may be approved on an individual case basis.

Recommended occlusive correction:

• before treatment of dentition is undertaken such as alteration, restoration, or reconstruction, wait until muscles and joints have normalized to allow reassessment.

Optional:

• occlusal adjustment after repositioning therapy or with orthodontic treatment
• restorative therapy
• orthodontic treatment (is less invasive than restorative therapy)

Referral to specialist

• Referral to: dental consultant with sub-specialty in TMJ, neurologist, orthopedic specialist, physiatrist or psychologist should occur as soon as the need is identified rather than after worker fails to respond to treatment.  Extent of WCB responsibility and effectiveness of interventions must be assessed on an individual basis.

Surgical

Surgical intervention is a last resort in terms of treatment with all of the following conditions being present before surgery is approved.  Moreover, surgical repair should not be expected to prevent further disease.

1. Documented TMJ disc displacement or other structural joint disorder with appropriate imaging
2. Positive evidence to suggest that the symptoms and objective findings are a result of disc displacement or other structural disorder(s)
3. Pain or dysfunction of such magnitude as to constitute disability to the patient.
4. Prior unsuccessful non-surgical treatment that includes orthotic appliance therapy, physical therapy, and behavioral therapy.
5. Prior management of bruxism, oral parafunctional habits, other medical and dental conditions, and other contributing factors that will affect the outcome of surgery.  [Adapted from The American Academy of Oral and Maxillo-facial Surgeons, 1984)

Fitness to work assessment criteria

Patients are usually not disabled.  Fitness to work should be assessed on an individual basis.

Current literature states that disorders of the TMJ are usually a self-limiting condition; symptoms beyond twelve months despite conservative treatment suggests chronic pain syndrome and requires further evaluation.

Permanent clinical impairment assessment criteria

• Permanent Clinical Impairment is not normally given for TMJ.
• When assessed, is based on the following :
• disk derangement
• decreased range of motion
• degenerative joint disease
• neurological disorders

[ back to top ]

---

Web site terms of use • Contact us