What are the common causes of TMJ neck pain. How can TMJ neck pain be effectively treated. What are the best strategies for preventing TMJ neck pain. How does TMJ neck pain relate to other TMJ symptoms. When should you seek medical attention for TMJ neck pain.

The Link Between TMJ Disorders and Neck Pain

Temporomandibular joint and muscle disorders (TMD), commonly referred to as TMJ disorders, are a group of conditions affecting the jaw joint and surrounding muscles. While jaw pain is a primary symptom, many individuals with TMD also experience neck pain. In fact, studies indicate that up to 70% of people diagnosed with a TMD report neck pain as a symptom.

The connection between TMJ disorders and neck pain lies in the complex relationship between the jaw and cervical spine. The temporomandibular joint, located on either side of the jaw, works in tandem with the muscles of the neck and upper back. When there’s dysfunction in the jaw joint, it can lead to muscle tension and pain that extends beyond the immediate area, affecting the neck region.

How Does TMJ Neck Pain Manifest?

TMJ neck pain typically presents as muscle tenderness and pain in the cervical spine area. This discomfort can range from mild to severe and may be accompanied by stiffness, reduced range of motion, and headaches. The pain may be constant or intermittent, often exacerbated by jaw movements such as chewing, speaking, or yawning.

Common Causes of TMJ Neck Pain

Understanding the root causes of TMJ neck pain is crucial for effective treatment and prevention. Several factors can contribute to the development of this condition:

• Teeth grinding (bruxism)
• Jaw clenching
• Poor posture
• Stress and anxiety
• Arthritis in the jaw joint
• Trauma or injury to the jaw or neck
• Misalignment of the jaw or teeth

These factors can lead to muscle imbalances, joint inflammation, and nerve irritation, all of which can contribute to neck pain associated with TMJ disorders.

Conservative Treatment Approaches for TMJ Neck Pain

When it comes to treating TMJ neck pain, medical professionals typically recommend starting with conservative, non-invasive approaches. These treatments aim to alleviate pain, reduce inflammation, and improve jaw and neck function without resorting to more aggressive interventions.

Lifestyle Modifications and Self-Care Techniques

Simple changes in daily habits can have a significant impact on managing TMJ neck pain:

• Eating soft foods to reduce stress on the jaw
• Applying heat or cold packs to the painful areas
• Avoiding extreme jaw movements
• Refraining from nail biting, gum chewing, and jaw clenching
• Practicing jaw stretching and relaxation exercises
• Maintaining good posture throughout the day

Medications for Pain Relief

Over-the-counter pain relievers and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help manage pain and reduce inflammation. In some cases, healthcare providers may prescribe stronger medications:

• Muscle relaxants
• Anti-anxiety medications
• Antidepressants (which can help with pain management)

Always consult with a healthcare professional before starting any new medication regimen.

Physical Therapy and Exercise

Physical therapy plays a crucial role in treating TMJ neck pain. A qualified physical therapist can design a customized exercise program to:

1. Improve jaw and neck flexibility
2. Strengthen supporting muscles
3. Correct postural imbalances
4. Teach proper jaw positioning and movement techniques

Regular practice of these exercises can significantly reduce pain and improve overall function.

Advanced Treatment Options for Persistent TMJ Neck Pain

When conservative treatments fail to provide adequate relief, healthcare providers may consider more advanced interventions. However, it’s important to note that the efficacy of these treatments can vary, and they should be approached with caution.

Intraoral Appliances

Intraoral appliances, also known as nightguards, splints, or stabilization appliances, are devices worn inside the mouth. They aim to reduce teeth grinding and alleviate pressure on the jaw joint. While some patients find relief with these devices, the National Institute of Dental and Craniofacial Research (NIDCR) notes that evidence supporting their effectiveness is limited.

Botox Injections

Botulinum toxin Type A (Botox) injections into the chewing muscles have been explored as a treatment for TMJ disorders. However, current evidence regarding its efficacy is limited, and more research is needed to establish its role in TMJ neck pain management.

Surgical Interventions

Surgery is typically considered a last resort for TMJ disorders due to its invasive nature and the lack of strong evidence supporting its long-term benefits. Surgical options may be explored only when all conservative treatments have failed and the pain significantly impacts quality of life.

Preventive Strategies for TMJ Neck Pain

Preventing TMJ neck pain involves addressing the underlying causes of TMJ disorders and maintaining good jaw and neck health. Here are some effective preventive measures:

• Wear a mouthguard at night to prevent teeth grinding
• Practice stress-reduction techniques such as meditation or yoga
• Maintain good posture throughout the day
• Avoid excessive gum chewing and nail biting
• Perform regular jaw and neck exercises as recommended by a physical therapist
• Address any dental issues promptly to prevent misalignment
• Use proper ergonomics when working or using digital devices

By incorporating these preventive strategies into daily life, individuals can significantly reduce their risk of developing or exacerbating TMJ neck pain.

Recognizing Other TMJ Symptoms

While neck pain is a common symptom of TMJ disorders, it’s often accompanied by other signs and symptoms. Being aware of these can help in early identification and treatment of the condition:

• Pain or tenderness in the jaw joint
• Aching pain in and around the ear
• Difficulty or discomfort while chewing
• Facial pain
• Locking of the jaw joint, making it difficult to open or close the mouth
• Clicking or popping sound when opening the mouth or chewing
• A change in the way the upper and lower teeth fit together

The presence of these symptoms alongside neck pain may indicate a TMJ disorder and warrant a consultation with a healthcare professional.

When to Seek Medical Attention for TMJ Neck Pain

While many cases of TMJ neck pain can be managed with self-care and conservative treatments, certain situations call for prompt medical attention. It’s important to recognize these “red flags” and seek professional help when necessary.

Red Flags Requiring Immediate Medical Evaluation

According to a 2018 medical article, the following symptoms should be considered red flags:

• Inability to open the mouth
• Persistent or worsening pain
• Tinnitus (ringing in the ears)
• Difficulty balancing
• Asymmetrical swelling of the jaw or neck
• Unexplained hearing loss
• Unintentional weight loss

If you experience any of these symptoms in conjunction with TMJ neck pain, it’s crucial to consult a healthcare provider promptly. These signs may indicate a more serious underlying condition that requires specialized treatment.

Persistent Pain and Treatment Resistance

Even if red flags are not present, individuals should seek medical attention if their TMJ neck pain:

• Persists for several weeks despite self-care measures
• Interferes with daily activities or sleep
• Does not respond to over-the-counter pain medications
• Is accompanied by significant jaw dysfunction

A healthcare professional can provide a comprehensive evaluation, accurate diagnosis, and develop a tailored treatment plan to address the specific needs of the patient.

The Role of Interdisciplinary Care in TMJ Neck Pain Management

Effective management of TMJ neck pain often requires a multidisciplinary approach. Various healthcare professionals may be involved in the diagnosis, treatment, and ongoing care of individuals with this condition:

• Dentists: To assess jaw alignment and dental health
• Oral and Maxillofacial Surgeons: For specialized evaluation of the jaw joint
• Physical Therapists: To provide exercises and manual therapy
• Chiropractors: For spinal adjustments and neck care
• Pain Management Specialists: To develop comprehensive pain relief strategies
• Psychologists: To address stress and anxiety related to chronic pain

Collaboration between these specialists can lead to more comprehensive and effective treatment plans, addressing all aspects of TMJ neck pain.

The Importance of Personalized Treatment Plans

Every case of TMJ neck pain is unique, and what works for one person may not be effective for another. Healthcare providers should tailor treatment plans to the individual’s specific symptoms, lifestyle, and health history. This personalized approach may include a combination of treatments, such as:

• Custom-fitted oral appliances
• Targeted physical therapy exercises
• Stress management techniques
• Dietary modifications
• Pharmacological interventions

Regular follow-ups and adjustments to the treatment plan are essential to ensure optimal outcomes and long-term relief from TMJ neck pain.

Emerging Research and Future Directions in TMJ Neck Pain Treatment

As our understanding of TMJ disorders and their relationship to neck pain continues to evolve, researchers are exploring new avenues for diagnosis and treatment. Some promising areas of investigation include:

• Advanced imaging techniques for more accurate diagnosis
• Regenerative medicine approaches, such as stem cell therapy
• Novel pharmacological agents targeting specific pain pathways
• Minimally invasive surgical techniques
• Wearable technology for real-time monitoring of jaw and neck movements

While these innovations are still in various stages of research and development, they hold potential for improving the management of TMJ neck pain in the future.

The Role of Patient Education and Self-Management

Empowering patients with knowledge and self-management skills is increasingly recognized as a crucial component of TMJ neck pain treatment. Healthcare providers are placing greater emphasis on:

• Educating patients about the nature of their condition
• Teaching proper jaw and neck biomechanics
• Providing resources for stress management and pain coping strategies
• Encouraging active participation in treatment decisions

This patient-centered approach can lead to better adherence to treatment plans, improved outcomes, and a greater sense of control over the condition.

TMJ neck pain: Causes, treatment, and prevention

Many people with temporomandibular joint and muscle disorders report pain in the jaw, but it can also cause a person to experience neck pain.

Temporomandibular joint and muscle disorders (TMD) is the term for several conditions that cause pain and dysfunction in the jaw joint and muscles that control jaw movement. People may also call them TMJ disorders.

TMJ is short for temporomandibular joint. This is the name for the two joints on either side of the jaw.

This article looks at whether pain associated with TMJ disorders can affect the neck. It also discusses how to treat the pain and how to prevent it.

TMJ disorders can cause a person to experience pain that affects the face, jaw, or neck. Up to 70% of people diagnosed with a TMD report neck pain as a symptom.

People will typically experience muscle tenderness and muscle pain in the cervical spine area. The cervical spine is the neck region of the spine.

Doctors usually recommend more conservative treatments.

According to the National Institute of Dental and Craniofacial Research (NIDCR), these include:

• eating soft foods
• applying heat or cold to the painful site
• avoiding extreme jaw movements
• avoiding nail biting, using chewing gum, or clenching the jaw
• learning and practicing jaw stretching and relaxing exercises
• using over-the-counter pain medicines or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen
• participating in behavioral therapies such as cognitive behavioral therapy or biofeedback
• massaging the neck muscles

According to MouthHealthy, doctors may recommend medications, including anti-anxiety medications, muscle relaxants, or antidepressants.

A person can also try complementary treatments, such as acupuncture or transcutaneous electrical nerve stimulation (TENs). However, there appears to be limited evidence to suggest that these can help TMDs.

If these treatments are not effective, a doctor may recommend other forms of treatment.

Intraoral appliances

Intraoral appliances are devices that a person places directly inside the mouth. Other names include nightguards, splints, or stabilization appliances.

The NIDCR notes that evidence suggesting that there is limited evidence to suggest these are effective at treating TMD pain.

If a doctor recommends that someone use one of these, people should ensure that it is not designed to change their bite permanently.

People should also stop using them and consult a dentist or doctor if pain develops.

Botox

Botox involves injecting botulinum toxin Type A into the muscles needed for chewing. However, there is limited evidence to suggest the efficacy of Botox as a treatment for TMD.

Surgery

Experts suggest that people should avoid treatments involving surgery or that make permanent changes to the jaw or teeth, as there is not enough supporting evidence to suggest that these treatments work.

If conservative treatments have not worked, surgery may be an option for some people. This surgery permanently changes a person’s joints. This is why doctors do not recommend it often.

The way to prevent TMJ neck pain is by aiming to prevent TMJ disorders in general.

A person may wish to:

• wear a mouthguard at night to prevent teeth grinding
• regularly exercise and stretch to help strengthen muscles in the neck and jaw area
• maintain good posture
• have regular physical therapy
• avoid clenching the jaw
• try to stop nail biting
• avoid chewing gum

Other symptoms that a person may experience alongside neck pain include:

• pain in the jaw joint
• pain in the muscles responsible for chewing
• pain in other areas of the face
• hearing loss
• dizziness
• ringing in the ears
• ear pain
• misalignment of the teeth
• clicking, grating, or popping causing pain when opening or closing the mouth
• limited jaw movement or locking
• grinding of teeth

Some people may experience all the above symptoms, whereas others may only experience some.

There is currently no standard test to diagnose a TMJ disorder. Therefore, it can be difficult to receive a diagnosis. However, people should speak with a doctor if they have pain that does not resolve using home remedies and treatments.

Doctors may refer people to a physical therapist who can design a bespoke exercise plan for them to follow to improve the flexibility and strength of the jaw.

People should contact a doctor if they have experienced trauma to their jaw or surrounding areas that seem to have caused the pain.

Additionally, if any of the following symptoms occur, people should consider these ‘red flags’ according to a 2018 article:

• inability to open the mouth
• persistent pain
• worsening pain
• tinnitus
• difficulty balancing
• asymmetrical swelling of the jaw or neck
• hearing loss
• weight loss

Some people with TMDs find that their symptoms resolve without treatment.

If a person needs treatment, experts usually recommend that this treatment be conservative and reversible. This helps resolve TMDs in most people.

Neck pain is a common symptom of TMDs and can often cause people a lot of discomfort.

Lifestyle changes and conservative treatment is usually enough to remedy this pain.

In more severe cases, doctors may recommend surgery, but it is important to remember that this is not reversible and can sometimes be ineffective or even worsen the problem.

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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Dysfunction of the temporomandibular joint (TMJ): symptoms, causes and treatment

Dysfunction (dysfunction) of the temporomandibular joint (TMJ) is one of the most common joint pathologies ^[1] , often found in dental practice. According to some data, about 80% of dental patients have temporomandibular joint dysfunction syndrome ^[1]

The main symptoms of TMJ dysfunction

Diagnosis of TMJ dysfunction is difficult, since the disorder manifests itself in the form of multiple and varied symptoms ^[2] . There are frequent cases when they spontaneously (spontaneously) arise and disappear ^[1] .

One of the most striking symptoms of the disorder is pain. At the same time, they can be so intense and sharp that the patient loses the ability to normally chew and swallow food, speak, and open his mouth. Pain may be the only symptom of the disorder, or it may be accompanied by characteristic clicks in the joint and limited mobility of the lower jaw. It is not uncommon for dysfunction to manifest itself only with sound phenomena, while other symptoms are absent ^[2]

Pain in TMJ dysfunction is localized not only in the articulation itself, but in the area of ​​masticatory muscles ^[4] . In addition, pain and discomfort can manifest itself in the forehead and eyes, ears, temples, head in general, spread (radiate) to the neck, shoulders and back ^[4] .

Other most common symptoms include ^[4]

• tinnitus;

• feeling of pressure on the eyes and sensitivity to light;

• dizziness, nausea, lack of concentration;

• clicks and other sounds during jaw movement;

• swelling in the facial area (mainly in the area of ​​the joint).

The discomfort associated with TMJ dysfunction can be severe enough to significantly reduce a patient’s quality of life ^[4] .

Causes of TMJ dysfunction

There are many causes behind TMJ dysfunction. Among them ^{[1, 2]}

• disorders of the psycho-emotional state of patients;

• head (maxillofacial region) and neck injuries;

• dentition defects with impaired closure and chewing function;

• fillings and dentures in the oral cavity;

• pathological abrasion of hard dental tissues;

• dental anomalies;

• periodontal diseases;

• bad habits and others.

As a rule, these factors act in a complex manner and increase the negative influence of each other, leading to the development of TMJ diseases.

The mechanism of the development of disorders, according to experts, is quite complex. If the lower jaw is symmetrical, the muscles of the head do not experience any tension. But if for some reason there are problems with the bite, the function of the chewing muscles is disrupted. In response to this, the spatial position of the lower jaw also changes. To hold it, the muscles of the head, neck, torso and even the lower extremities are additionally strained ^[2]

For several months, and in some cases even years, the patient may not notice muscle tension. But if additional negative facts arise (stress, bruxism ), TMJ dysfunction develops ^[2] .

Arthritis and arthrosis of the temporomandibular joint

TMJ dysfunction leads to such dangerous pathologies as chronic arthritis, and then arthrosis of the joint ^[1] .

Arthritis of the TMJ is an inflammatory disease. Negative factors that can provoke its development are hypothermia, hormonal changes, and pathologies of the nervous system. Acute arthritis may be preceded by exacerbation of sinusitis, tonsillitis or otitis media ^[6] .

Symptoms of TMJ arthritis: joint pain that may radiate to different areas of the face. At the same time, pain is less intense at rest. In acute arthritis, there may be swelling in the joint area, the jaw is shifted to the affected side. The patient complains of general malaise, weakness, he may have an increased body temperature.

Arthrosis of the TMJ develops due to excessive stress on the joint. As a rule, this disease is accompanied by an irreversible change in the tissues of the joint, first cartilage, and then bone. Arthrosis often develops as a complication of arthritis of the temporomandibular joint. A characteristic symptom is a feeling of stiffness, pain in the jaw area after sleep and towards the end of the day ^[6] .

Arthritis and arthrosis of the temporomandibular joint can occur with complications and require complex, often surgical treatment. And in the absence of therapy, they can lead to serious conditions of the patient, limitation of his activity ^[7] and even disability ^[4] .

Treatment of TMJ dysfunction

TMJ dysfunction requires complex and long-term treatment, rehabilitation and subsequent prevention of recurrence of the disorder ^[4] .

Treatment of patients with TMJ dysfunction is a very complex and multifaceted problem. There cannot be a single and simple treatment regimen here, since the same correct diagnosis requires the doctor to influence various adverse factors that caused and continue to maintain the TMJ pain dysfunction syndrome in each patient -mandibular joint, Ph.D. Shemonaev V. I.

As a rule, the treatment of TMJ includes several directions ^{[4, 6]} .

1. Dental therapy. First of all, they carry out sanitation of the oral cavity (treatment of caries, pulpitis). In addition, if necessary, eliminate foci of infection in the oral cavity, tonsils, maxillary sinuses.

2. Orthopedic therapy. In order to normalize the bite, prosthetics are performed, grinding of irregularities in fillings.

3. Medical therapy. It is aimed at reducing chronic and acute pain with the help of a variety of pain medications and alleviating the patient’s condition. In addition, anti-inflammatory therapy is also carried out.

4. Physiotherapy. Includes electrical stimulation, ultrasound and magnetotherapy, phototherapy, compresses, massage. They help to relax muscles and eliminate spasms.

5. Therapeutic gymnastics. It should include exercises both for the chewing muscles and for developing a healthy posture and the habit of correct movements (the so-called motor stereotype).

6. Psychotherapy. Includes a variety of methods and tools aimed at reducing the overall stress of the patient (including conversations with a psychotherapist, auto-training, sleep restoration).

7. Other means. Used according to the specific symptoms of TMJ dysfunction and other diseases or conditions of the patient. For example, in case of manifestations of bruxism, special protective caps or splints are used to help eliminate involuntary grinding of the teeth and prevent abrasion of their surface.

Treatment of arthritis and arthrosis of the TMJ, in addition to general therapeutic measures, necessarily includes unloading the joints, for which they are trying to immobilize ^[6] . If the inflammation is purulent, the necessary surgical intervention (puncture) is performed. Also, surgical treatment is performed in complex cases of arthrosis, when the temporomandibular joint is subjected to significant deformation ^[6] .

List of sources

1. Vyazmin A. Ya., Podkorytov Yu. M., Klyushnikov OV Temporomandibular joint dysfunction and its treatment // Innovation Science. 2015. No. 1-2. URL: https://cyberleninka.ru/article/n/disfunktsiya-visochno-nizhnechelyustnogo-sustava-i-ego-lechenie (date of access: 20.02.2020).

2. Besschastny DS, Vyazmin A. Ya., Klyushnikov OV, Podkorytov Yu. M. Pathogenesis of temporomandibular joint dysfunction // Acta Biomedica Scientifica. 2010. No. 5. URL: https://cyberleninka.ru/article/n/patogenez-disfunktsii-visochno-nizhnechelyustnogo-sustava (date of access: 03/06/2020).

3. Shemonaev V. I., Mikhalchenko D. V., Kuznetsova O. A., Klimova T. N., Poroshin A. V. Dental rehabilitation of patients with combined pathology of occlusion and dysfunction of the temporomandibular joint // Volgograd Medical Scientific Research magazine. 2013. No. 2 (38). URL: https://cyberleninka.ru/article/n/stomatologicheskaya-reabilitatsiya-patsientov-s-sochetannoy-patologiey-okklyuzii-i-disfunktsiey-visochno-nizhnechelyustnogo-sustava (date of access: 03/06/2020).

4. Silant’eva EN Multidisciplinary approach to the diagnosis and treatment of craniomandibular dysfunction of the temporomandibular joint [Electronic resource] / EN Silant’eva // Topical issues of medical prevention, diagnosis and treatment of dental diseases: Sat. Art. intl. scientific-practical. Conf., Minsk, May 17, 2019 / Belorus. state honey. un-t, 2nd department. therapist. dentistry; under total ed. T. N. Manak, L. G. Borisenko, L. N. Polyanskoy. – Minsk, 2019. http://rep.bsmu.by/bitstream/handle/BSMU/23943/170_178.pdf?sequence=1&isAllowed=y (accessed 03/06/2020).

5. Yakupov BR, Gerasimova LP Diagnosis and treatment of muscular-articular dysfunction of the temporomandibular joint with pain syndrome // Medical Bulletin of Bashkortostan. 2013. No. 1. URL: https://cyberleninka.ru/article/n/diagnostika-i-lechenie-myshechno-sustavnoy-disfunktsii-visochno-nizhnechelyustnogo-sustava-s-bolevym-sindromom (date of access: 03/06/2020).

6. Artyushkevich AS Diseases of the temporomandibular joint // Modern Dentistry. 2014. No. 1 (58). URL: https://cyberleninka.ru/article/n/zabolevaniya-visochno-nizhnechelyustnogo-sustava-1 (date of access: 03/06/2020).

7. Tarasov IV, Nikitin AA et al. Conservative treatment of arthrosis of the temporomandibular joint // Bulletin of Modern Clinical Medicine. 2016. No. 4. URL: https://cyberleninka.ru/article/n/konservativnoe-lechenie-artroza-visochno-nizhnechelyustnogo-sustava (date of access: 20.02.2020).

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, crackling/clicking when opening or closing the mouth, and blockage of the mandible are all indications of damage to the TMJ itself and facilitates diagnosis.

Diagnostics and differential diagnostics

Previously, TMD was considered exclusively as a pathology of the TMJ and as a consequence of subluxation of the lower jaw, 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 during provocative tests: palpation in or around the condylar process of the mandible or with maximally active or passive mouth opening, 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 TMJ 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 TMD 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 the 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.

For chronic TMD it is recommended:

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 the 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 lack of effect of conservative therapy, the patient should be referred to an oral surgeon [30].

TMD is considered today as the most common cause of chronic facial pain not associated with dental disease. 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. If typical symptoms of intra-articular pathology (primarily sound) are detected, an MRI of the joint is indicated to confirm the diagnosis.

TMD is currently considered a disease with a multifactorial etiology. Myofascial pain syndrome in the muscles of the masticatory group can be considered as a manifestation of a violation of antinociceptive functions, i.e., it is a reflection of central sensitization and a violation of downward pain control.

Treatment of the painful form of TMD at the first stage should be carried out by a neurologist.