Rosen & Barkin's 5-Minute Emergency Medicine Consult (699 page)

See Also (Topic, Algorithm, Electronic Media Element)

Excited Delirium Syndrome, Puncture Wounds

CODES

• 919.8 Other and unspecified superficial injury of other, multiple, and unspecified sites, without mention of infection
  
• 994.8 Electrocution and nonfatal effects of electric current
  

BASICS

• Myofascial pain causing temporomandibular joint (TMJ) dysfunction
  
• Prevalence of 40–75% of 1 sign of TMJ disorder
  
• Most common in 20–50-yr-olds
  
• Females seek treatment more frequently
  
• 40% have symptoms that resolve spontaneously
  
• TMJ is a synovial joint:
  
  • Allows for hinge and sliding movements
    
• Articular disorders:
  
  • Congenital or developmental
    
  • Degenerative joint disorders:
    
    • Inflammatory (rheumatoid arthritis)
      
    • Noninflammatory (osteoarthritis)
      
  • Trauma
    
  • TMJ hypermobility:
    
    • Laxity
      
    • Dislocation
      
    • Subluxation
      
  • TMJ hypomobility:
    
    • Trismus
      
    • Fibrosis
      
  • Infection
    
  • Neoplasm
    
• Masticatory muscle disorders:
  
  • Local myalgias
    
  • Myositis
    
  • Muscle spasm
    
  • Contracture
    
  • Myofascial pain disorder
    
• TMJ clicking:
  
  • May be normal finding; present as a transient finding in 40–60% of the population
    
• TMJ motion:
  
  • Typical range is 35–55 mm (maxillary to mandible incisors)
    
  • Limited by adhesions within the joint or disk displacement or trismus from muscle spasm
    
• Intra-articular disk disorder:
  
  • Anterior displacement with reduction:
    
    • Displacement in closed mouth position
      
    • Often with a click and variable pain with opening mouth
      
    • May worsen over time
      
  • Anterior disk displacement without reduction:
    
    • Disk is a mechanical obstruction to opening mouth
      
    • Maximal opening may be 20–25 mm
      
    • Often difficult to correct
      

TMJ dysfunction is poorly understood:

• Multifactorial:
  
  • Bruxism (teeth grinding)
    
  • Trauma
    
  • Malocclusion
    
• Onset may be related to stress
  

DIAGNOSIS

• Preauricular pain:
  
  • Constant but with fluctuating intensity
    
  • Dull and aching
    
  • May be referred to the ipsilateral ear, head, neck, or periorbital region
    
  • Exacerbated by mandibular movement (pathognomonic)
    
  • More conspicuous at night and may cause insomnia
    
  • Often worsens through the day
    
• Tongue, lip, or cheek biting
  
• Ear pain
  
• Ear fullness
  
• Tinnitus
  
• Dizziness
  
• Neck pain
  
• Headache
  
• Eye pain
  

• Joint sounds:
  
  • Popping or clicking sensation with TMJ articulation
    
  • A palpable or audible click with opening and closing
    
  • Not sufficient for diagnosis if not accompanied by pain or other dysfunction
    
• Misalignment and limited range of motion:
  
  • Dentoskeletal malocclusion or lateral deviation
    
  • Open or closed locking of the jaw
    
• Tenderness over the muscles of mastication and TMJ:
  
  • Masseter muscle most commonly painful
    
• Pain with dynamic loading (bite on gauze)
  

• Diagnosis based on history and physical exam
  
• Exclude other causes of headache and facial pain
  

No specific lab tests are indicated unless there is concern for other disease process, i.e., ESR may help distinguish temporal arteritis from TMJ dysfunction.

• Panorex is the screening radiograph of choice:
  
  • May demonstrate fracture or intra-articular pathology (i.e., tumor or degenerative joint disease) but usually unremarkable
    
• CT: Best for evaluating bony structures for fractures, dislocations, etc.
  
• MRI: Best imaging for nonreducing displaced disks:
  
  • Allows for better visualization of joints simultaneously
    

• Acute coronary syndrome
  
• Carotid artery dissection
  
• Intracranial hemorrhage (subarachnoid hemorrhage)
  
• Inflammatory diseases:
  
  • Giant cell (temporal) arteritis
    
  • Rheumatoid arthritis
    
• Trigeminal or glossopharyngeal neuralgia
  
• Vascular headache
  
• Intraoral and dental pathology
  
• Herpes zoster
  
• Salivary gland disorder
  
• Otitis media, otitis externa
  
• Sinusitis
  
• Elongated styloid process pain
  
• Jaw trauma (fracture or dislocation)
  

TREATMENT

Provide comfort and reassurance

Make sure airway is patent

• Acute therapeutic options:
  
  • Patient reassurance and education—”usually mild and self-limited”
    
  • Rest
    
  • Heat
    
  • Analgesics and anxiolytics
    
  • Urgent reduction of open or closed locking TMJ
    
  • Reduction of TMJ dislocation:
    
    • Dislocation usually bilateral
      
    • IV muscle relaxant may be helpful
      
    • Often requires procedural sedation
      
    • Monitor airway
      
    • May face the patient or perform from behind the patient
      
    • Protect thumbs with gauze and/or tongue depressors
      
    • Thumbs rest on intraoral surface of mandible
      
    • Fingers wrap around jaw
      
    • Firm, progressive downward pressure as jaw is guided 1st in a caudal direction and then posteriorly
      
  • Physical therapy—moist heat or ice packs
    
  • Pain site injections with mixture of steroids/lidocaine
    
• Outpatient management:
  
  • Combination pharmacotherapy:
    
    • NSAIDs
      
    • Muscle relaxants
      
    • Antidepressants
      
    • Sedative hypnotics
      
  • Home physical therapy—moist heat or ice packs and mechanically soft diet
    
  • Caution not to open mouth >2 cm for 2 wk
    
  • Avoid triggers such as gum chewing
    
  • Occlusal appliance worn during sleep
    
  • Referral to dentist or oral–maxillofacial surgeon
    

• Naproxen: 250–500 mg PO BID (peds: 10 mg/kg/d PO div. q12h)
  
• Cyclobenzaprine: 5–10 mg PO TID (peds: 5–10 mg PO TID if >15 yr old); caution with hepatic impairment
  
• Diazepam: 2–10 mg PO BID–TID (peds: <12 yr old 0.12–0.8 mg/kg/d PO div. q6–8h); poor efficacy when used alone
  
• Ibuprofen: 600 mg (peds: 10 mg/kg) PO q8h; less effective than naproxen
  

• Nortriptyline: 10–50 mg PO qhs
  
• Narcotic analgesic
  
• Sedative hypnotics
  

FOLLOW-UP