Temporomandibular Joint Dysfunction (TMD)

The temporomandibular (TMJ) joint is what allows people to talk and chew comfortably; over-exertion of this joint can lead to a variety of disorders referred to as temporomandibular joint dysfunction (TMD).

• The TMJ is the most constantly used joint in the body.
• Minor problems can be caused by teeth clenching and grinding that often occur as a result of emotional stress or anxiety.
• This can trigger joint symptoms, as well as spasm of the chewing muscles, headaches, and neck pain.
• If your child has trauma in his lower jaw, it can cause rapid shearing of the joint, which may require treatment.

The temporomandibular joint (TMJ) is located at the spot where the lower jaw meets the skull base. The muscles and ligaments surrounding the joint work together to allow it to move. The health of those surrounding muscles and ligaments — and the health and position of your child’s teeth — all contribute to the proper alignment and functioning of the TMJ.

TMD can arise because of over-exertion of your child’s TMJ. Some examples of conditions that can cause this over-exertion are high levels of stress or anxiety, grinding or clenching of the teeth, or trauma to the jaw.

This is a common problem, which can often be treated at home. More severe cases of TMD may require physical therapy, dental treatments, or surgery.

Children and adolescents are more likely to develop TMD as a result of stress or trauma to the jaw. In younger children, congenital jaw deformities can lead to TMD.

Many parents are concerned about TMD and can have lots of questions about the condition and how it can affect their child.

You may find it helpful to jot down questions as they arise. When you talk to your doctor, you can be sure that all of your concerns are addressed.

Here are some questions to get you started:

• What is causing my child’s TMD?
• Are there any tests we should do to confirm the diagnosis?
• What can we do at home to help relieve the pain?
• Will my child have to have surgery?
• Do the medications you’re prescribing have any significant side effects?
• Will the symptoms of TMD go away? What is my child’s long-term outlook?

If your child has any of the following symptoms, you may want to check with a doctor:

• Difficulty opening the mouth
• Difficulty closing the mouth
• Jaw pain
• Jaw fatigue
• Ear aches or ringing in the ear
• Unexplained headaches
• Popping or clicking of your joint with pain
• Locking of the jaw
• Asymmetrical jaw opening
• Uneven vertical or lateral movements of the jaw
• Pain when touching the TMJ
• Swelling around the TMJ
• Jaw asymmetry or malocclusion

TMD can be caused by several factors:

• Teeth clenching or grinding
• Stress or anxiety
• Trauma to the jaw or the joint
• Muscle spasms
• Misalignment of the jaw (malocclusion)
• Arthritis

If your child is suffering from TMJ pain, there are several things you can do to help prevent it worsening:

• Rest the jaw joint when it becomes tender.
• Avoid hard or chewy foods that can strain face muscles.
• Use moist heat to help relaxation the surrounding muscles.
• Monitor your child's stress and anxiety levels.
• Have a dentist evaluate your child for grinding or clenching of teeth.

If the pain persists, your doctor may recommend dental or surgical treatment.

While there is no standard test to identify TMD, your child’s symptoms and a physical exam will be adequate for diagnosis.

The physical examination includes:

• Feeling your child's jaw joints and surrounding muscles for discomfort
• Listening for clicking, popping, or grinding sounds
• Examining your child’s jaw movement
• Examining your child’s mouth and teeth

The doctor will also review your child’s dental and medical history before making a diagnosis and starting treatment.

If your child's doctor wants more information about the health of the joint and any possible misalignment of the jaw, she may order any of the following tests:

• Panoramic X-ray: This X-ray uses small doses of ionizing radiation to produce a film of your child’s mouth, teeth, and jaws
• MRI (magnetic resonance imaging): A radiographic exam that uses a large magnet, radio waves, and a computer to produce two- and three-dimensional images of your child's jaw, muscles, and mouth
• CT scan (computed tomography): a radiographic exam that uses X-ray equipment and powerful computers to create detailed, cross-sectional images of your jaw and mouth.

After we complete all necessary tests, experts from the oral and maxillofacial surgery department, dentistry, or otolaryngology (ear, nose, and throat) may meet to review and discuss what their findings.

There is a range of options for how your child's doctor may choose to treat his TMD based on how severe his symptoms are. For many children, self-care will be enough to manage TMD; for others, however, physical therapy, dental treatments and joint surgery may be needed.

Self-care

Many minor TMJ problems can often be cared for at home with no other treatment needed. Here are some tips that may reduce the discomfort from TMD:

• Have your child rest the jaw joint when it becomes tender.
• Avoid hard or chewy food that can strain face muscles.
• Use moist heat to help relax your child's facial muscles.
• Teach your child to perform range-of-motion jaw exercises.
• Monitor your child's stress and anxiety levels.
• Ask your child's dentist to evaluate him for grinding or clenching of teeth.

Medications

Your child's oral and maxillofacial surgeon may prescribe anti-inflammatory medications and/or muscle relaxants to help alleviate jaw pain and encourage easier jaw movement.

Physical therapy

If home care isn't enough, a physical therapist can help your child with stretching and strengthening, which can reduce pain. There are a variety of possible treatments, including:

• Jaw exercises
• Posture training
• Electrical stimulation: Low-level electrical currents can help relax your child's jaw joint and facial muscles
• Ultrasound: Deep heat can be applied to a sore or immobile joint
• Biofeedback: A type of relaxation therapy that uses electronic instruments to give your child immediate feedback about what effect the relaxation exercises are having on his jaw joint and facial muscles

Dental treatment/splint therapy

If your child is clenching or grinding his or her teeth, his doctor may suggest that a dentist make a nightguard or splint to protect your child's teeth and jaw.

Surgery

Most children with TMD will not require surgery. However, if your child needs surgery, physicians in our Oral and Maxillofacial Surgery Program can help your child get better, faster. Here are the different kinds of surgery used to treat severe TMD.

• Arthrocentesis: This is a minimally invasive procedure where two needles are inserted through the skin into the temporomandibular joint space. The surgeon then injects sterile fluid to break up adhesions and to clean the joints.
  • Medications to lubricate the joint may be added at the end of the procedure to help reduce inflammation or pain
• Arthroscopy: An endoscope (a small flexible tube with a camera attached to it) is inserted into the joint in order to see where the problems are.
  • The endoscope may be used to remove cartilage fragments and scar tissue
• Open joint surgery: In this surgery, the surgeon makes an incision and then removes, reshapes, or repositions parts of the joint to reduce pain and improve its function.
• Joint replacement: If your child's TMJ is so damaged that it needs to be replaced, the surgeon can reconstruct the joint using autogenous or synthetic materials.
• Orthognathic (jaw) surgery: If your child's pain is a result of malocclusion (misalignment of the jaw), the doctor may recommend jaw surgery to correct the problem.

The surgeons at the Robotic Surgery Research and Training Program at Boston Children's Hospital are dedicated to helping your child get better faster.

Arthrocentesis is a minimally invasive procedure to treat TMD.

• Two needles are inserted through the skin into the temporomandibular joint space and sterile fluid is injected to break up adhesions and to cleanse the joints.
• Medications to lubricate the joint may be added at the end of the procedure to help reduce inflammation or pain.

Physicians and researchers in Boston Children’s Oral and Maxillofacial Surgery Program combine a tradition of surgical excellence with innovative research.

Research projects include:

Shelly Abramowicz, DMD, MPH, is using MRI to study TMD in children with arthritis with the goal of diagnosing this condition as early as possible. Read more on this study.

Dr. Abramowicz has also researched and compared different TMJ reconstruction systems including custom and Bioment prostheses.