What are the common causes of jaw pain. How can you identify symptoms of TMJ disorders. What treatment options are available for jaw-related issues. When should you seek medical attention for jaw discomfort. How do dental problems contribute to jaw pain. Can jaw pain be a sign of more serious health conditions. What home remedies can help alleviate jaw pain.

Understanding Temporomandibular Joint (TMJ) Disorders

Temporomandibular joint (TMJ) disorders are among the most frequent causes of jaw pain, affecting approximately one in eight individuals. These conditions primarily impact the joints connecting the jawbone to the skull, located just in front of the ears. TMJ disorders can significantly impair a person’s ability to open and close their mouth comfortably.

Several factors can contribute to the development of TMJ disorders:

• Jaw injuries
• Underlying health conditions, such as arthritis
• Teeth grinding or clenching (bruxism)
• Misalignment of the jaw
• Inflammation in the surrounding muscles
• Stress

Recognizing the symptoms of TMJ disorders is crucial for early intervention and effective management. Common signs include:

• Clicking sounds when opening the mouth
• Pain or ache around the ears, face, or jaw
• Persistent headaches
• Tinnitus (ringing in the ears)
• Dizziness
• Visual disturbances
• Difficulty or pain while chewing
• Jaw locking

Diagnosing and Treating TMJ Disorders

If you suspect you have a TMJ disorder, it’s essential to seek professional evaluation. A doctor or dentist can provide an accurate diagnosis and recommend appropriate treatment options. Initial treatments often include:

• Over-the-counter pain relievers like acetaminophen or ibuprofen
• Jaw exercises to strengthen muscles
• Lifestyle modifications, such as avoiding gum chewing and nail biting
• Custom-fitted bite guards to prevent teeth grinding

In more severe cases, prescription medications or surgical interventions may be necessary to address TMJ disorders effectively.

Trauma-Induced Jaw Pain: Causes and Management

Jaw pain can also result from physical trauma, such as a blow to the face or a fall. Traumatic injuries to the jaw can lead to various complications, including:

• Bruising and swelling
• Intense pain
• Loose or dislodged teeth
• Difficulty opening or closing the mouth

How can you manage jaw pain resulting from trauma? In many cases, over-the-counter pain medications and a soft food diet can help alleviate discomfort during the healing process. However, persistent pain or difficulty moving the jaw warrants immediate medical attention to rule out more serious injuries.

Dental Issues as a Source of Jaw Discomfort

Numerous dental problems can manifest as jaw pain, making regular dental check-ups crucial for maintaining oral health. Common dental issues that may cause jaw discomfort include:

• Toothaches caused by cavities or abscesses
• Cracked, crowded, or temperature-sensitive teeth
• Periodontal disease affecting the jawbone
• Erupting wisdom teeth
• Misaligned teeth or bite issues
• Bruxism (teeth grinding or jaw clenching)

What should you do if you suspect a dental problem is causing your jaw pain? It’s essential to consult your dentist promptly for a thorough examination and appropriate treatment. In the meantime, rinsing your mouth with warm water and carefully flossing around the affected area can provide temporary relief.

Jaw Pain Associated with Joint Problems and Arthritis

Certain types of arthritis, particularly rheumatoid arthritis, can affect the temporomandibular joints, leading to jaw pain and stiffness. Rheumatoid arthritis is an autoimmune condition that causes inflammation in the body’s tissues, including the cartilage that facilitates smooth jaw movement.

How does arthritis impact jaw function? The inflammation and damage to the joint cartilage can result in:

• Reduced range of motion in the jaw
• Pain during jaw movement
• Stiffness, especially in the morning
• Clicking or popping sounds when opening or closing the mouth

Managing arthritis-related jaw pain often involves a combination of medication, lifestyle changes, and physical therapy. In some cases, working with a rheumatologist and a dentist specializing in TMJ disorders can help develop a comprehensive treatment plan.

Infectious Diseases and Their Impact on Jaw Health

While less common due to widespread vaccination, certain infectious diseases can still cause jaw pain and related symptoms. Two notable examples are:

Mumps

Mumps is a viral infection that primarily affects the salivary glands, causing swelling and pain in the jaw area. The inflammation can make jaw movement difficult and uncomfortable.

Tetanus

Tetanus, a bacterial infection, can lead to severe muscle stiffness, including in the jaw muscles. This condition, often referred to as “lockjaw,” can be life-threatening and requires immediate medical attention.

How can you protect yourself from these infections? Staying up-to-date with vaccinations is crucial for preventing these diseases and their associated jaw complications.

Jaw Pain as a Potential Indicator of Heart Problems

In some cases, jaw pain can be a symptom of a more serious underlying condition, such as a heart attack. This phenomenon, known as referred pain, occurs when discomfort originating in one part of the body is felt in another area.

Why might jaw pain signal a heart attack? The nerves that serve the heart and those that serve the jaw are interconnected, which can lead to jaw pain during a cardiac event. It’s important to note that for some individuals, jaw pain may be the only noticeable symptom of a heart attack.

Other potential causes of referred jaw pain include:

• Shoulder joint problems
• Lower back issues

Given the potential seriousness of heart-related jaw pain, it’s crucial to seek immediate medical attention if you experience unexplained jaw discomfort, especially if it’s accompanied by other symptoms such as chest pain, shortness of breath, or nausea.

Sinus Problems and Their Relation to Jaw Discomfort

Chronic sinusitis, a condition characterized by long-term inflammation of the sinus cavities, can sometimes manifest as pain in the upper jaw. This occurs due to the proximity of the sinuses to the upper jaw and teeth.

What are the common symptoms of chronic sinusitis that may affect the jaw?

• Difficulty breathing through the nose
• Tenderness around the eyes and cheeks
• Aching sensation in the upper jaw
• Facial pressure or pain
• Reduced sense of smell

Treatment for sinus-related jaw pain typically involves addressing the underlying sinus inflammation through medications, nasal irrigation, or in some cases, surgical intervention.

Trigeminal Neuralgia: A Rare but Severe Cause of Facial Pain

Trigeminal neuralgia is a painful condition that affects the trigeminal nerve, which is responsible for transmitting sensory information from the face to the brain. This condition can cause intense, shock-like pain in various parts of the face, including the jaw.

What triggers trigeminal neuralgia? The condition is often caused by:

• Compression of the trigeminal nerve by a blood vessel
• Multiple sclerosis
• Tumors or other structural abnormalities

Trigeminal neuralgia pain is typically characterized by:

• Sudden, severe, stabbing sensations
• Pain that feels like an electric shock
• Discomfort that affects one side of the face, often the jaw or cheek
• Episodes triggered by everyday activities like eating, talking, or touching the face

Treatment for trigeminal neuralgia may include medications to control nerve pain, surgical procedures to relieve pressure on the nerve, or in some cases, radiation therapy.

Home Remedies and Lifestyle Changes for Managing Jaw Pain

While professional medical care is often necessary for addressing jaw pain, several home remedies and lifestyle modifications can help alleviate discomfort:

1. Apply hot or cold compresses to the affected area
2. Practice gentle jaw stretches and exercises as recommended by a healthcare provider
3. Maintain good posture to reduce strain on the jaw and neck
4. Avoid hard or chewy foods during flare-ups
5. Use relaxation techniques to manage stress, which can exacerbate jaw pain
6. Consider using an over-the-counter mouth guard to prevent nighttime teeth grinding
7. Massage the jaw muscles gently to promote relaxation and improve circulation

It’s important to note that while these remedies can provide relief, they should not replace professional medical advice, especially for persistent or severe jaw pain.

When to Seek Medical Attention for Jaw Pain

While some cases of jaw pain may resolve on their own or with home care, certain situations warrant immediate medical attention. Seek professional help if you experience:

• Severe, persistent pain that doesn’t respond to over-the-counter pain relievers
• Difficulty opening or closing your mouth
• Jaw pain accompanied by fever, which could indicate an infection
• Swelling or visible deformity of the jaw
• Jaw pain that occurs suddenly and is accompanied by chest pain or shortness of breath
• Persistent clicking or popping sounds when moving your jaw
• Pain that significantly interferes with eating, speaking, or daily activities

Early intervention can often prevent the progression of jaw-related issues and lead to more effective treatment outcomes.

The Importance of Interdisciplinary Care for Jaw Pain

Given the complex nature of jaw pain and its various potential causes, an interdisciplinary approach to diagnosis and treatment is often beneficial. Depending on the underlying cause of your jaw pain, you may need to consult with multiple healthcare professionals, such as:

• Dentists or orthodontists for dental-related issues
• Oral and maxillofacial surgeons for severe TMJ disorders or jaw injuries
• Neurologists for conditions like trigeminal neuralgia
• Rheumatologists for arthritis-related jaw pain
• Otolaryngologists (ENT doctors) for sinus-related problems
• Physical therapists for jaw exercises and muscle strengthening
• Pain management specialists for chronic jaw pain

Collaborating with various specialists can ensure a comprehensive approach to diagnosing and treating your jaw pain, addressing all potential contributing factors.

Preventive Measures to Reduce the Risk of Jaw Pain

While not all causes of jaw pain are preventable, there are steps you can take to reduce your risk of developing jaw-related issues:

1. Practice good dental hygiene to prevent tooth decay and gum disease
2. Wear a mouthguard during contact sports to protect against jaw injuries
3. Avoid excessive gum chewing or nail biting, which can strain the jaw
4. Address stress through relaxation techniques or counseling to reduce teeth grinding and jaw clenching
5. Maintain proper posture, especially when working at a desk or using electronic devices
6. Eat a balanced diet rich in calcium and vitamin D to support bone and joint health
7. Stay hydrated to promote overall joint health and reduce inflammation

By incorporating these preventive measures into your daily routine, you can help maintain optimal jaw health and reduce the likelihood of developing painful conditions.

The Role of Imaging in Diagnosing Jaw Pain

When investigating the cause of jaw pain, healthcare providers may utilize various imaging techniques to obtain a clearer picture of the jaw’s structure and function. Common imaging methods include:

• X-rays: To visualize bone structure and detect fractures or arthritis
• CT scans: For detailed 3D images of the jaw and surrounding tissues
• MRI: To evaluate soft tissues, including the jaw’s cartilage and muscles
• Ultrasound: To assess joint movement and detect inflammation

These imaging techniques can help healthcare providers make accurate diagnoses and develop targeted treatment plans for jaw-related issues.

Emerging Treatments for Chronic Jaw Pain

As research in the field of jaw disorders continues to advance, new treatment options are being developed to address chronic jaw pain. Some emerging treatments include:

• Botulinum toxin injections to relax overactive jaw muscles
• Regenerative therapies using platelet-rich plasma or stem cells
• Advanced minimally invasive surgical techniques for TMJ disorders
• Neurostimulation devices to manage chronic facial pain
• Customized 3D-printed jaw implants for severe cases

While many of these treatments are still in various stages of research and development, they offer hope for individuals suffering from persistent jaw pain that has not responded to conventional therapies.

Why Does My Jaw Hurt? 6 Possible Causes of Jaw Pain

Written by Matt Smith

Medically Reviewed by Robert Brennan on March 23, 2023

• What Is Jaw Pain?
• What Causes Jaw Pain?
• Jaw Pain Treatment and Home Care

Jaw pain can be a sign of something as common as a toothache — or even something as serious as a heart attack. Your jawbone, also called a mandible, connects to your skull at a pair of joints known as the temporomandibular joints, or TMJs. These joints are just in front of your ears, and they let you open and close your mouth.

Your jaw also holds your teeth and gums, which can be sensitive to heat, cold, or pressure. They also can get infected if you don’t keep them clean.

TMJ disorders

This is one of the most common reasons for jaw pain. About 1 in 8 people may have a TMJ disorder. It’s more common among women.

Causes of TMJ disorders include:

• An injury to your jaw
• Certain illnesses or conditions, like arthritis
• Grinding or clenching your teeth
• Your jaw not lining up the way it should
• Inflammation in the muscles around your jaw

Stress can worsen it, too.

Symptoms of TMJ disorders include:

• Clicking sound when you open your mouth
• Pain or ache around your ears, face, or jaw
• Constant headaches
• Ringing in your ears
• Dizziness
• Vision problems
• Pain when you chew or a hard time chewing
• Locking of your jaw

If you think you might have a problem with your TMJ, get it checked out. Usually, your doctor or dentist may have you take over-the-counter drugs like acetaminophen or ibuprofen for pain. They also might recommend that you exercise your jaw muscles to strengthen them, and to quit chewing gum or biting your nails. You might also get a plastic bite guard to keep you from grinding your teeth. Sometimes, you might need prescription drugs or surgery to fix the problem.

Trauma

Like any bone, you can knock your jaw out of place or break it. A blow to the jaw can cause:

• Bruises
• Swelling
• Pain
• Loose or knocked-out teeth

Usually, over-the-counter pain medication or steps like eating soft foods will help ease your discomfort as you heal. But if the pain won’t go away, or you can’t open and close your mouth right, you’ll need medical care. Issues with teeth alignment can also sometimes cause jaw pain. Learn more about the different treatment options related to an overbite and jaw pain.

Dental problems

A bunch of issues with your teeth can lead to jaw pain. They include:

• A toothache, usually because of a cavity or an abscess
• Teeth that are cracked, crowded, or sensitive to temperature or pressure
• Gum disease, which can damage your jawbone
• Wisdom teeth coming in
• Misaligned teeth
• Grinding your teeth or clenching your jaw.

See your dentist right away for these problems. Until then, you can rinse your mouth with warm water and use dental floss to get rid of any bits of food around the tooth that hurts.

Joint problems

If you have a type of arthritis known as rheumatoid arthritis, it could attack your temporomandibular joints. It’s an autoimmune disease, which means your body mistakenly attacks healthy tissue and makes it swell up. That may damage the soft, spongy cartilage that keeps your jaw moving smoothly, which can make it feel stiff and sore.

Diseases

Vaccines have largely gotten rid of diseases. But some people still get them, and the symptoms can include jaw pain.

• Mumps. You catch it from a virus. It swells the glands on the side of your mouth that make saliva. The pain can make it hard to move your jaw.
• Tetanus. You get this bacterial infection through a cut or a scratch on your skin. An early sign is that your jaw muscles might feel tight or stiff. The spasms are often called lockjaw. This serious illness can put you in the hospital for weeks.

Heart attack

It may sound odd, but jaw pain sometimes can signal a heart attack. Pain that starts near a cluster of nerves, like your heart, can be felt someplace else on the body. This is called referred pain. For some people, jaw pain may be the only symptom of a heart attack.

Referred pain in the jaw also may be a sign of joint problems, such as in the shoulders or the lower back.

Sinus problems

If the spaces inside your nose and under your eyes (your sinuses) stay swollen and inflamed for longer than 3 months, even with treatment, you may have a condition called chronic sinusitis. It mainly makes it hard to breathe through your nose and makes the area around your eyes feel tender, but chronic sinusitis also can cause aching in your upper jaw.

Trigeminal neuralgia

This painful condition can happen when a blood vessel presses against the trigeminal nerve, which carries messages to your brain from your face.  It can also be caused by multiple sclerosis. Trigeminal neuralgia usually affects one side of your jaw or cheek and can feel like a stabbing pain or a jolt of electricity. The pain can be so severe that it keeps you from being able to eat or drink.

Cluster headaches

These are very painful headaches that happen in certain patterns or happen often in a short amount of time. They cause serious pain on one side of your head and often wake you up during the night. Cluster headaches usually affect the area around your eyes and temple, but the pain can spread to your jaw as well.

Osteomyelitis

This is an infection that happens in a bone. It can affect your lower jaw (or mandible), a condition called anaerobic osteomyelitis. If it’s not treated, the infection can cut off the blood supply to your jaw and permanently damage the bone tissue there.

Tumors or cysts

These are growths in your jawbone or the soft tissues in your mouth and face. Sometimes called odontogenic tumors and cysts, they’re not often cancerous, but they can grow quickly and affect your teeth. In most cases, surgery is recommended to take them out.

Treatment for your jaw pain will depend on what’s causing it, but a few things may help with general discomfort:

• Resting your jaw
• Over-the-counter pain medicines, like anti-inflammatories and analgesics
• Prescription medicines, including antidepressants for pain, or muscle relaxants
• Cold compresses for 10 to 20 minutes at a time, 3 or 4 times a day
• Gentle exercises to strengthen and stretch the muscles in your jaw or face
• Ultrasound (high-powered sound waves) to help with pain and swelling

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Do You Have TMJ? 8 Symptoms Not to Ignore

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Temporomandibular joint disease, or TMJ, is a complex condition that often worsens over time. Typically caused by the misalignment of the teeth, TMJ can erode the joint capsule between the skull and the jawbone. It is tricky to diagnose, and some people suffer for years. Once it is properly recognized, though, TMJ responds well to treatment. Here are 8 symptoms you should never ignore.

Not everyone experiences TMJ in the same way, but a clicking or popping sound in the jaw is an extremely common symptom. If this is your only symptom, you might not need treatment, but it is important to make your dentist aware right away.

2. Pain with Jaw Movement

When the teeth are not properly aligned, the jaw muscles try to compensate. Pain in the jaw or ear while chewing is common. Some people also experience pain when yawning or speaking.

3. Other Pain

TMJ can cause referred pain in the form of headaches, neck pain, shoulder aches, and even toothaches. The pain may worsen when moving the jaw, but it can sometimes be felt even at rest.

4.

Locking Jaw

A lockup in the jaw can be a sign of TMJ. You might have difficulty opening your mouth wide or closing it again. When you do get it to move, your jaw will likely pop into place with a loud click.

5. Tired Facial Muscles

The muscles of your face may work hard to compensate for TMJ. If your face feels tired or saggy on one side, let your dentist know. Some people have persistent discomfort, while others experience it only after using the jaw.

6. Trouble Chewing

Since the jaw is out of alignment, many people with TMJ have trouble chewing. Your muscles will try to compensate, but this may be impossible if the misalignment is severe. You might feel like your teeth aren’t closing properly, and you might have extreme difficulty with foods that are crunchy or chewy. Check your bite in the mirror to ensure that your top and bottom teeth meet evenly without any straining or stretching.

7. Facial Swelling

It is relatively uncommon, but some people with TMJ have swelling on one side of the face, likely due to damage and inflammation in the joint capsule. The swelling may be mild or severe, and it might appear only after using the jaw or persist even at rest.

8. Nonspecific Symptoms

TMJ is challenging to diagnose because it can cause many different nonspecific symptoms. These may include, but are not limited to, dizziness, hearing difficulties, and ringing in the ears. Log any unusual symptoms you experience to discuss with your dentist at your next appointment.

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What to do if your jaw hurts at home

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• WHAT TO DO WITH PAIN IN THE JAW

Pain in the teeth and gums is most often associated with dental problems. In such cases, it is clear what to do if the jaw hurts – go to the dentist. But the problem is that it is difficult to determine by the nature of the pain that this is the field of dentistry or another branch of medicine. Studies, including radiography, help to establish the exact cause: OPTG, CBCT of the jaw, CT of the TMJ.

Jaw hurts on the right or left: what to do

If the jaw hurts after tooth extraction, this is a typical phenomenon. Even in simple cases, pain is observed after the effect of anesthesia ends. If the “seventh” tooth or a wisdom tooth with complex multiple roots was removed, then there is a pronounced injury to the tissues in the oral cavity. Pain may accompany the patient for 3-7 days. An alarming signal is an increase in edema: normally, inflammation should subside, and pain should decrease.

What to do when your jaw hurts:

• Determine the nature of the pain. Normally, it should be aching, and not sharp and pulsating.
• Pay attention to the condition of the socket: the blood clot must be in place. If he fell out due to the wrong actions of the patient (chewed with the sick side, touched the wound, touched with a toothbrush), then there is a possibility of developing alveolitis.
• Check if there is a discharge. The presence of flux can be both a complication of extraction and indicate that the flux developed before tooth extraction, which means that the patient was diagnosed poorly without the use of radiographic methods.

What should I do when my jaw hurts after a tooth extraction? With all these symptoms, contact the clinic where your tooth was removed. During the removal process, a nerve can be affected, another complication is osteomyelitis (bone inflammation). If you are extracting a tooth that was already very painful, do a CT scan of the jaw or OPTG to determine the exact cause and prevent complications from developing.

What to do if your jaw hurts when you open your mouth

The TMJ is an extremely mobile joint involved in speech, chewing and swallowing. The temporomandibular joint tenses when we are nervous, and if the patient has bruxism, then the TMJ does not rest even at night. Any disruption in the functioning of the TMJ leads to problems. The joint is surrounded by tissues with a large number of nerve endings, so the response to a malfunction is pain. Please note that pain when opening the mouth can also be observed in diseases not associated with the TMJ, for example, in ENT diseases.

In case of joint disease, the patient also complains of other symptoms. Already at the stage of questioning the patient, the doctor can first decide what to do if the ear and jaw hurt. If pain from the joint is given to the ear, first of all, instrumental diagnostics are prescribed. Other symptoms of TMJ involvement:

• Difficulty in jaw movement or, conversely, hypermobility outside the normal range.
• Clicking when moving the jaw.
• Puffiness.
• Redness.
• Facial asymmetry.
• Partial closure.

Do not attempt to self-treat TMJ problems – this can lead to joint blockage and disability. The doctor prescribes medication and physiotherapy, bite correction, prosthetics for adentia, special splints (depending on the indications). Before visiting a doctor, reduce the load on the chewing apparatus: eat soft food, talk less, avoid active facial expressions, avoid overheating (do not visit a bath or sauna).

One side of the jaw hurts: what to do

One-sided pain may indicate the following problems:

• Teething. Most often, adults are worried about the eruption of “eights” – wisdom teeth. Possible complications: growth at an angle due to lack of space, inflammation of the gingival hood (pericoronitis).
• Deep caries, pulp damage, periodontitis. Symptoms usually appear when pressing on the tooth, chewing. What to do if the jaw hurts when chewing? Chew on the healthy side and see your doctor right away. If the pain is disturbing even without exposure to an irritant, we can talk about pulpitis. Possible complications – inflammation of the gums, destruction of bone tissue, sepsis.
• Mistakes made during treatment: incorrect canal treatment, high filling margins, unsuitable crowns.
• Flux (determined by the presence of cheek swelling).
• Cyst at the root (visible only on X-ray).
• Inflammation of the lymph nodes.

What should I do if the right or left side of my jaw hurts? First of all visit the dentist. Most often, the dentist will determine the cause.

What to do if your lower or upper jaw hurts

Sometimes the cause of the disease can be preliminarily determined by the localization of pain, but this does not negate a full examination of the patient. Sometimes pain is not associated with diseases of the teeth and gums, which requires additional consultation of specialists:

• The upper jaw may hurt due to inflammation of the trigeminal nerve, sinusitis and diseases of the paranasal sinuses, migraine.
• The lower jaw may ache due to inflammation or trauma to the TMJ. In this case, the pain can spread beyond the jaw and affect the temples, ears, forehead, cheeks. In addition, pain is observed with inflammation of the submandibular lymph nodes – usually the pain is localized on the right or left. Other causes: neuralgia, diseases of the cardiovascular system.

In most cases, a CT scan is enough to find the root of the problem. If the disease is not associated with teeth and gums, an extended examination is necessary, and the patient is referred to a traumatologist, oncologist, neurologist, cardiologist, otolaryngologist or other specialist.

External examination gives the doctor limited information. In order not to be mistaken with the conclusions, OPTG or CBCT of the jaw is always prescribed. You can undergo an examination on a modern PLANMECA PRO MAX 3D unit in Moscow at an independent 3D MEDICA center.

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Temporomandibular joint dysfunction as the most common cause of facial pain: current state of the problem

Orofacial pain is widespread in the population. Patients with facial pain seek medical advice from many specialties, including dentists, maxillofacial surgeons, neurologists, internists, and otorhinolaryngologists. Diagnosis of pain in the face can cause a serious difficulty for the doctor.

Pain in the face can be caused by a variety of reasons. In the International Classification of Head and Facial Pain, 3rd revision (ICHD-3 beta), pain syndromes in the facial area are given in Chapter 11 “Headache or facial pain associated with the pathology of the bones of the skull, neck, eyes, ears, nose, sinuses, teeth , oral cavity or other structures of the face and neck” and in chapter 13 “Painful cranial neuropathies and other facial pains” [1]. It should be noted that almost all sections in Chapter 11 use the term “headache (HA)”; only one section mentions facial pain as such (11. 8). Chapter 13 refers to pain syndromes as “neuralgia” or “neuropathy.”

Most of the syndromes listed in the ICGB are not often encountered in the practice of a neurologist. One of the common mistakes in interpreting the cause of facial pain is the overdiagnosis of trigeminal neuralgia (TN) followed by prolonged and ineffective treatment with carbamazepine. At the same time, TN has been shown to be a relatively rare cause of facial pain [2].

This article focuses on temporomandibular joint dysfunction (TMJD). Today, TMD is regarded as the most common cause of chronic facial pain not associated with dental disease [3]. Facial pain associated with pathology in the region of the temporomandibular joint (TMJ) occurs in 19—26% of the adult population, and in women it is observed 1.5 times more often than in men [4, 5].

Clinical picture

Patients with TMD may experience pain in the face, maxilla and mandible, neck and shoulders, and in and around the ear. The pain may be constant or appear when chewing, talking, opening the mouth. Often the pain is also accompanied by a feeling of tiredness in the face and swelling.

In addition to facial pain, patients may experience headache, neck pain, earache, toothache, burning and stabbing sensations in the face, and shooting and puncture sensations. In addition to pain, there are also more rare and therefore even more difficult to diagnose symptoms: noise, ringing or congestion in the ears, non-systemic dizziness, and even itching or tingling in the head and neck. Pain may develop gradually, but many patients report an abrupt onset of pain and accompanying symptoms.

Difficulty chewing, inability to open the mouth wide, a crackling/clicking sound when opening or closing the mouth, and blockage of the mandible are all indications of damage to the TMJ itself and facilitate diagnosis.

Diagnostics and differential diagnostics

Previously, TMD was considered exclusively as a TMJ pathology and as a consequence of mandibular subluxation, arthritis, arthrosis or trauma of the TMJ, as well as occlusal disorders [6, 7]. However, in 2014, the TMD Diagnostic Criteria for Clinical Practice and Research (DC/TMD) was adopted by the International RDC/TMD Consortium Network and Orofacial Pain Special. interest group). In accordance with these criteria, TMD is divided into two groups: pain and intra-articular pathology; their combination is also possible [8].

A large number of patients with TMD have a painful form, i.e. pain in the area of ​​masticatory muscles, while the pathology of the joint itself is not detected. The literature describes pain in the face associated with myofascial dysfunction of the facial muscles [7, 9]. The authors indicate that during palpation of the muscles on the side of pain, a dense texture and muscle tension, especially masticatory and facial muscles, as well as severe pain and myofascial trigger points, were noted. On palpation of the masticatory muscle, the pain spreads to the upper and lower jaws, upper and lower molars, to the ear, to the frontal region, to the TMJ, to the neck. On palpation of the temporal muscle, pain radiates to the corresponding half of the head, forehead, upper teeth, and orbit. Since the prevalence of the painful form of TMDJ exceeds the prevalence of the intra-articular form [10], most patients can and should receive effective care from a neurologist. Thus, facial pain in a patient is most often caused by hypertonicity and myofascial pain syndrome in masticatory muscles without pathological changes in the structures of the joint itself.

When a patient presents with facial pain, the neurologist needs to conduct a proper examination (palpation) in order to diagnose and optimally treat such patients. This will avoid unnecessary referral of patients to dentists and ENT doctors and unnecessary and often painful examinations.

New criteria for the correct diagnosis of TMD are presented in the table.

Criteria for the diagnosis of TMD DC/TMD for use in clinical practice and research (adapted from [8])

Thus, according to the diagnostic criteria for TMD for clinical use, pain disorders are not associated with the pathology of the TMJ itself and can be represented by myalgia, arthralgia and HT associated with TMD. These criteria are based on the data of the anamnesis and clinical examination (palpation of the temporal and masticatory muscles) and do not require mandatory imaging studies. In myalgia, pain may be felt in the jaw, temple, ear, or anterior to the ear and usually changes with mandibular movement, chewing, or parafunctional activity. This means that pain in the face, ear, anterior and near the ear, as well as tinnitus may be symptoms of TMD and not indicate the presence of ENT pathology.

In the case of local myalgia, the pain felt by the patient is reproduced by palpation of the temporal and masticatory muscles within their palpable area. In myofascial pain syndrome, pain extends beyond the palpable area within or outside the palpated muscle (myofascial pain syndrome with referred pain).

It should be noted that for a complete diagnosis, it is necessary to follow the correct muscle palpation protocol: 3 points in the temporal muscle (anterior, middle and posterior sections) and 3 points in the masticatory muscle region (the beginning of the muscle, its body and its attachment site) [11]. Palpation is carried out with one or two fingers on each side separately or on both sides at once (depending on the convenience of the patient), the duration of pressing to determine myalgia should be at least 2 s, if it is necessary to determine the subtype of myalgia, at least 5 s. In practice, it is also possible to palpate the masticatory muscle by pressing it with the researcher’s thumb in the patient’s mouth and with the rest of the fingers outside.

To determine the presence of arthralgia, it is necessary to confirm that the pain felt by the patient in the face is localized in the TMJ region and is reproduced by provocative tests: palpation in the region or around the condylar process of the mandible or with maximum active or passive opening of the mouth, lateral movement or protrusion of the mandible .

In the case of localization of pain in the parotid region anterior to the auricle, it can be difficult for the clinician to determine the specific structure involved. In this case, it is necessary to determine whether the pain is localized in the region of the condylar process of the lower jaw (arthralgia) or the masticatory muscle. In the latter case, one of the types of myalgia will be diagnosed. To determine the location of the condylar process of the jaw and confirm the source of pain felt by the patient, it is necessary to palpate the anterior region with the mouth closed. In case of difficulty, palpation should be performed when opening the mouth or protruding the lower jaw forward (Fig. 1).

Rice. 1. Palpation to locate the condylar process of the mandible. a – with a comfortable closing of the mouth; b – with protrusion of the lower jaw.

To find the points of palpation of the masticatory muscle, ask the patient to clench and then unclench his teeth. In this case, the definition of the boundaries of the palpated muscle is greatly simplified (Fig. 2).

Rice. 2. Palpation of the masseter muscle to determine the form of TMD. a – the place of the beginning of the muscle; b – muscle body; c — zone of muscle attachment.

Palpation of the temporal muscle is much easier. It is necessary to palpate at least 3 points in the anterior, middle and posterior portions of the muscle (Fig. 3). In case of difficulty in finding the boundaries of the temporal muscle, it is necessary to ask the patient to clench his teeth.

Rice. 3. Palpation of the temporal muscle in order to determine the form of TMD. a – anterior portion of the muscle; b – the average portion of the muscle; in — a back portion of a muscle.

Another type of pain form of TMD is the headache associated with TMD. In ICHD-3, beta HT associated with TMD is referred to as secondary cephalalgia and is described as “HT caused by a disorder involving structures in the TMJ area” [1]. The first two items are non-specific criteria confirming the secondary nature of the pain; only item 3 contains TMD-specific characteristics: GB is provoked or exacerbated by active jaw movements, passive movements in the usual range of jaw mobility, and/or provocative tests with temporomandibular structures, such as pressure on the TMJ and surrounding masticatory muscles. However, the commentary on the diagnostic criteria contains a recommendation from the International Headache Society to use newer and more accurate criteria developed by the RDC/TMD International Network Consortium and the Orofacial Pain Research Group to fully diagnose and clarify the causes of pain associated with TMD.

Differential diagnosis of HT associated with TMD includes other forms of primary and secondary cephalgia. When conducting a differential diagnosis, it is necessary to rely on the known diagnostic criteria for these cephalalgias. In the case of strictly unilateral HA, it is necessary to exclude migraine and cervicogenic GB. Patients with migraine are characterized by provocateurs of a painful attack that are not typical for TMD, migraine symptoms accompanying an attack (nausea, vomiting, phono- and photophobia), often a hereditary history of G.B. To confirm the diagnosis of cervicogenic HA, rotational tests and diagnostic blocks of cervical structures are used [1]. In the case of bilateral localization of pain, difficulties may arise in the differential diagnosis with tension headache, combined with tension of the pericranial muscles. In this case, the inspection and palpation shown in Fig. 1-3 are of key importance for diagnosis.

Intra-articular forms of TMD are somewhat less common in the practice of a neurologist. It should be noted that in many cases the identified intra-articular pathology is combined with the pain form of TMD and is not isolated.

In the presence of damage to the TMJ itself, there are several forms of TMD. With various forms of displacement of the intraarticular disc with reduction, different intracapsular sounds are noted during palpation of the joint and movements of the lower jaw: crunching, crackling, clicking. Disc displacement without reduction is usually caused by spasm of the lateral pterygoid muscle [12]. When the disc is displaced without reduction, there is a pronounced restriction of mouth opening and a violation of the ability to eat. In the case of degenerative pathology of the disc, a coarser (similar to grinding) and long sound can be noted – crepitus caused by friction of the damaged intraarticular disc. Blockage of the TMJ when the mouth is open and the inability to close the mouth without an assisted maneuver are indicative of mandibular subluxation.

Examination rules for the diagnosis of intra-articular form of TMD are shown in fig. 4. To confirm the diagnosis of various intra-articular forms of TMD, it is necessary to conduct an MRI examination of the joint.

Rice. 4. Palpation aimed at detecting sounds in the TMJ. a — when opening/closing the mouth; b – lateral movement of the jaw to the right; c – lateral movement of the jaw to the left; g – protrusion of the lower jaw. Palpation is carried out sequentially on each side.

Etiology and pathogenesis of TMD

The etiology of TTMJ is multifaceted and is a combination of psychological, postural, orthopedic, genetic, biopsychosocial and occlusive factors that disrupt the functional balance in the structures of the TMJ itself and its surrounding muscles [6, 13, 14].

The view on the pathophysiology of TMD cannot be considered finalized. In 1934, James Costen gave the first systematic description of this group of diseases, indicating occlusion failure as the main cause. For many years, it was believed that the cause of myogenic and articular disorders in TMDJ is malocclusion (occlusal disorders, missing teeth, suboptimal prosthetics, chewing on one side and other causes) and parafunctional activity (night and/or daytime bruxism), which leads to increased load on the TMJ and muscles that provide chewing (temporal, chewing, medial and lateral pterygoid). A significant role was also assigned to injuries of the face and lower jaw and emotional disorders. In particular, the presence of symptoms of depression doubles the likelihood of developing the arthralgic form of TMD, and anxiety disorders often accompany myalgia in TMD [15, 16]. Some authors [7] point to the role of orthopedic disorders (for example, short leg syndrome) in the genesis of TMD. An orthopedic examination in a significant number of patients (66%) reveals asymmetries of the shoulders, shoulder blades, shortening of one leg, which causes a compensatory change in posture and muscle imbalance throughout the entire spine. The “forward head posture” also has a serious influence on the occurrence of the myogenic form of TMD [17].

However, in recent years, a number of authors have expressed doubts about the exclusive role of dental pathology in the development of TMD. Point to the frequent combination of TMD and various types of GB. In patients with TMD, the most common primary form of HA is migraine (55.3%), the prevalence of HA is 30.2% [18]. According to other authors [19], the prevalence of TMD in patients with chronic daily HA is 58.1%.

In recent years, in the works of leading Russian and foreign researchers of chronic pain [20—22], for the first time, suggestions were made about possible central causes of TMD, in particular, about the role of a possible dysfunction of pain control systems. Thus, it has been shown that the prevalence of the pain form of TMD in chronic migraine significantly exceeds that in episodic migraine. The authors hypothesized that pain and myofascial pain syndrome in TMD may be caused by impaired processing of pain impulses in the CNS and are not associated with peripheral/dental factors.

Treatment

Based on the current understanding of the pathophysiology of TMD, a range of treatments have been developed. In neurological practice, the treatment of TMD includes a wide range of non-drug and pharmacological approaches:

1. Patient education. Educating patients about the causes and form of TMD and the importance of behavior modification (eg, actively focusing on not clenching teeth) is important. In case of acute pain, it is necessary to recommend a temporary refusal to eat solid food and open the mouth wide.

2. Non-steroidal anti-inflammatory drugs (NSAIDs) are often the first choice and are effective in managing TMD pain. Among a large group of NSAIDs, the drug nimesulide (nise) deserves special attention. The difference in clinical efficacy and tolerability of different NSAIDs may be due to different selectivity for inhibition of COX-1 and COX-2. Nimesulide is predominantly a COX-2 inhibitor with a wide range of additional actions, which helps to explain its specific anti-inflammatory and analgesic activity. More than 200 clinical studies have evaluated the effectiveness of nimesulide in a wide range of pain syndromes (tooth extraction and other dental operations, GB, back pain, joint pain, dysmenorrhea). In these studies, nimesulide systematically demonstrated a reduction in inflammatory pain significantly superior to placebo and at least equal to or in some cases even more effective than other NSAIDs [23].

The main clinical benefit of nimesulide is the time to onset and duration of pain relief. Compared with other NSAIDs, nimesulide has a faster onset of analgesic action, namely 15 minutes after ingestion [24], it should also be noted that a rapid onset of action was noted in patients with chronic pain syndrome.

A significant advantage of this drug is a lower relative risk of complications of the upper gastrointestinal tract compared with non-selective NSAIDs due to the predominant effect on COX-2. However, a single dose of nimesulide provided higher efficacy and a faster onset of analgesia than comparable single doses of selective COX-2 inhibitors such as celecoxib and rofecoxib [25]. When comparing nimesulide with the non-selective NSAID diclofenac, the drug showed comparable efficacy, but better overall tolerability [26].

The overall risk of severe liver reactions associated with the use of NSAIDs is low. The incidence of liver damage associated with the use of nimesulide is within the frequency range for other NSAIDs [23].

The use of all NSAIDs is associated with some cardiovascular risk and in patients with arterial hypertension, hypercholesterolemia and cardiovascular disease, all NSAIDs should be used with caution, especially in the elderly. Risks and benefits should be assessed on an individual basis and the lowest effective dose is recommended for the shortest possible period of time. Many data indicate that nimesulide demonstrates a low overall risk of cardiovascular events such as myocardial infarction or congestive heart failure [27].

An international panel of experts concluded that when used appropriately, nimesulide remains an extremely important and safe treatment option for various conditions characterized by the presence of acute inflammatory pain, due to the rapid onset of analgesic action and a proven positive benefit/risk profile [23].

Nise is recommended for TMD at a dose of 100 mg twice daily. The duration of its use, like other NSAIDs, should be limited to the minimum necessary time.

3. Gymnastics . After applying a cold compress, exercises are performed to stretch the masticatory muscles, then a warm towel must be applied.

4. Cognitive behavioral therapy and biofeedback are also highly effective.

Recommended for chronic TMD:

1. Administration of the tricyclic antidepressant amitriptyline (up to 75 mg/day). The choice of amitriptyline as a first-line drug is due to the relatively high risk of developing bruxism while taking selective serotonin reuptake inhibitors [28].

2. Referral of the patient to the dentist for the selection of a special muscle relaxant splint (especially in case of nocturnal bruxism) and assessment of the presence and correction of occlusal disorders.

3. In case of myofascial pain syndrome, it is possible to inject anesthetic into trigger points in masticatory, temporal and pterygoid muscles.

4. Treatment with botulinum toxin type A for the painful form of TMDJ, which has demonstrated high efficacy in a large number of studies [9, 29]. Such therapy can not only achieve long-term and sustainable relaxation of the muscles of the masticatory group and relieve pain associated with myofascial pain syndrome in these muscles, but also a temporary remission of nocturnal bruxism, which will reduce the risk of developing an intra-articular form of TMD.

5. Carrying out complex treatment of comorbid diseases, in particular depression, anxiety disorders, chronic pain.

6. In case of proven presence of intra-articular form of TMD, dysfunction of the jaw and the absence of the effect of conservative therapy, the patient should be referred to an oral and maxillofacial surgeon [30].

TMD is now regarded as the most common cause of non-dental chronic facial pain. It has been shown that facial pain in many cases is caused by hypertonicity and myofascial syndrome in masticatory muscles without pathological changes in the structures of the joint itself. Since the prevalence of the painful form of TMDJ exceeds the prevalence of the intra-articular form, most patients can and should receive effective care from a neurologist. For a complete diagnosis of the nature of TMD, one should rely on the DC/TMD diagnostic criteria for clinical use. These criteria are based on the history and clinical examination (correct palpation of the temporalis and masticatory muscles) and do not require mandatory imaging studies.