A 17-year-old female came to clinic with complaints of mouth pain and headaches. The pain had occurred bilaterally in her cheeks for most days over the past 1-2 weeks. She denied any throat, mouth or ear pain. She also complained of bilateral, temporal headaches that seemed to go to the back of her head. These had happened 2-3 times over the 1-2 weeks and they improved with acetaminophen or ibuprofen and rest. She wasn’t sure how long either pain lasted. The cheek pain was worse at night but did not awaken from her sleep and were better in the morning. She had noticed that the cheek pain was starting to occur earlier in the day though.
The review of systems was negative for any systemic complaint. She denied any trauma. The social history revealed that she wasn’t sleeping much at night because she was studying for college credit and final examinations. Additional history identified that she was now not doing her usual daily running, was eating more candy when she studied and had started to chew gum. She said that she would chew about 1-2 packs/day starting after school. She also confided that she was biting on her pens or pencils. She denied grinding her teeth. The past medical history showed intermittent tension headaches in the past. There was no dental, neurological or other systemic problems. The family history was non-contributory.
The pertinent physical exam showed a healthy appearing female with normal growth parameters and vital signs. Her facial structures looked symmetrical. There were no abnormalities on palpation of her skull and facial bones. She was able to open her mouth more than 3 cm and could move her jaw laterally about 8 mm. This did elicit pain in the temporomandibular joint area at the extremes of movement as did clenching her teeth. Her pharynx looked normal and tapping teeth did not elicit any pain. Her ears were normal as was her neck. The rest of her examination was negative including her neurological examination.
The diagnosis of muscle pain due to overuse was highly suspected as no other obvious pathology could be found. The pediatrician recommended that she stop chewing gum and biting pencils. He also recommended that she try to do at least some physical exercise every day as a way to help with her stress. “I know you don’t think you have lots of time, but you will feel much better and be more productive when you do your studying. Instead of chewing candy, how about drinking water or another low-calorie beverage. You can also use a squishy ball, play dough or something else in your hand to fidget with if you want. Getting up often will also help your studying because you need a break. I’d recommend that you check your chair and posture so you don’t hurt your other muscles too. Do you have a good light? You need one when you are studying,” he counseled. He also recommended that she could use some acetaminophen or ibuprofen if needed for acute pain. “If this is getting worse or not improving in a few days, then I think you should see your dentist,” he also recommended.
The mandible normally grows in a symmetric downward and forward movement relative to the skull base. The condyle is the primary growth center. “The mandible is unique in that its 2 joints and growth centers function together as a single unit.” It is the last bone in the body to reach skeletal maturity. The mandible and its growth are important for maxillary growth and therefore many problems that affect the mandible affect the facial and skulls structures as well. These growth problems can be relatively insidious and therefore may need monitoring over longer periods of time such as patients with underlying congenital problems, systemic illnesses or condylar trauma.
Temporomandibular joint disorders (TMJ) are a group of craniofacial pain problems that commonly present with pain, restricted or abnormal movement or sounds during motion. TMJ problems are broadly classified as articular or joint problems, masticatory muscle disorders, headache disorders or associated structure disorders. Problems can occur at any age but prevalence in the pediatric age group increases with age. Some studies report 5-10% for children with mixed dentitia and 5-33% for adolescents.
Physical examination should be performed to help elucidate the problems but specialist help may be necessary such as dental or otolaryngological consultation. Facial symmetry and jaw movement should be inspected. Palpation of the TMJ during mouth opening, closing, lateral movements and clenching of the jaw should be evaluated. Palpation of the various muscles also helps with evaluation. Close inspection of the oral structure including the posterior pharynx and dentitia (including tapping of the teeth to try to elicit individual tooth problems) is appropriate. Range of motion is accessed by measuring distances. The normal vertical interincisal opening is 35-55 mm in adults, whileless than 25-30 mm is abnormal. Lateral movement is normally 8-9 mm (about the size of the mandibular central incisor). One study of 3-5 year olds found a maximal vertical opening of 40 mm, lateral movement of 6.5 mm, and protrusive excursion of 6 mm.
Clicking or crepitus on exam should be noted.
Non-surgical treatment is usually a combination of patient education, behavioral intervention, physical therapy and pharmacotherapy. Families need to be educated about the particular problem and then have a reasonable home care plan to include avoiding irritating movements (avoiding hard or chewy foods, taking small bites, chewing on both sides of the mouth, avoiding chewing gum, clenching the jaw or tongue thrusting), using warm or cold compresses, and keeping the jaw in a neutral position (i.e. teeth apart and masticatory muscles relaxed). Therapy to help with awareness of some contributing behaviors such as relaxation training, biobehavioral or biofeedback and cognitive behavioral therapies can be used. A variety of physical therapies can be tried including massage, manipulation, and ultrasound. Customized appliances to help stabilize or position oral structures can also provide relief as can a variety of anti-inflammatory and other pain medications. Treatment for underlying and co-morbid problems such as arthritis, headaches and acquired or congenital structural abnormalities obviously need to be addressed and they are key to the treatment plan. These may involve more invasive treatment including surgeries.
A differential diagnosis of TMJ problems includes:
- Fracture or trauma
- Joint or bone problems
- Arthritis (particularly juvenile rheumatoid arthritis) and other arthritides and systemic diseases
- Disc problems
- Infection – septic joint, postinflammatory
- Hypomobility – ankylosis, adhesion/adherence, intercondylar reabsorption
- Hypermobility – subluxation, dislocations
- Synovial problems
- Muscle problems
- Myofascial pain with spreading, referred or due to systemic disease/illness
- Movement problem – orofacial dyskinesia, oromandibular dystonia
- Muscle or tendon contracture
- Occlusal problems
- Overuse problems
- Congenital disorders
- Syndromic including overgrowth syndromes
- Conversion disorder
- Psychosocial problems
- Headache – usually tension
- Movement disorders – muscular dystrophy, Bell’s palsy etc.
- Neuropathic pain – Fabry’s disease, complex regional pain syndrome, cancer, herpes zoster, HIV
- Iatrogenic – radiation therapy
Questions for Further Discussion
1. What are indications for consultation with a dentist?
2. What are indications for consultation with an otolaryngologist?
3. What causes dental pain?
4. How is bruxism treated?
- Disease: Temporomandibular Joint Problems | Jaw Injuries and Disorders
- Symptom/Presentation: Dental Problems | Pain
- Specialty: Dentistry / Orthodontia | Otolaryngology
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Jaw Injuries and Disorders
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Bender ME, Lipin RB, Goudy SL. Development of the Pediatric Temporomandibular Joint. Oral Maxillofac Surg Clin North Am. 2018 Feb;30(1):1-9.
Horswell BB, Sheikh J. Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children. Oral Maxillofac Surg Clin North Am. 2018 Feb;30(1):11-24.
Scrivani SJ, Khawaja SN, Bavia PF. Nonsurgical Management of Pediatric Temporomandibular Joint Dysfunction. Oral Maxillofac Surg Clin North Am. 2018 Feb;30(1):35-45.
Galea CJ, Dashow JE, Woerner JE. Congenital Abnormalities of the Temporomandibular Joint. Oral Maxillofac Surg Clin North Am. 2018 Feb;30(1):71-82.
Chouinard AF, Kaban LB, Peacock ZS. Acquired Abnormalities of the Temporomandibular Joint. Oral Maxillofac Surg Clin North Am. 2018 Feb;30(1):83-96.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa