Temporomandibular joint pain

The evidence which I have compiled indicates that the bulk of temporomandibular cases, of indirect traumatic origin, can be divided into two pathologic categories: (1) those occurring within the joint structure including contusion, osteoarthritis, and occasionally rheumatoid arthritis in this order of frequency, and (2) those occurring periarticularly with functional alterations of the external pterygoid muscles. The two categories may occur solely or concomitantly. The temporomandibular joint is extremely flexible and normally is the victim rather than the active guide of the opening tilt. This joint and the external pterygoid muscle, when injured or strained, create an area of hyperesthesia or oversensitiveness and are capable of producing considerable psychogenic disturbances. The degree and chronicity of the involvement depend upon the nature of the injury to the external pterygoid muscle, probably the superior fasciculus of this muscle. The initial injury can arise from compression by the condyle head, either in an anterior glide, lateral rotation, or during the opening tilt, or to an injury, strain, or fatigue within the external pterygoid muscle. The nature of the problem is different with a posteriorly displaced condyle, which produces more tearing, than with a condyle in an anterior position, which is a compression problem. Any diagnosis of temporomandibular complaints must start at the level of the joint itself, and not at the level of the dental arches. There are other causes of pain in this area, such as constitutional, the external acoustic meatus, fluid collecting in the infratemporal fossa, the coronoid process, and the posterior and insertion fibers of the temporal muscles. Any one of these could he the sole cause for pain in this area. Fig. 6 shows in outline a minimum spectrum of thought in diagnosing these cases. This is a simple, specific technique for diagnosing these joint complaints, for ascertaining the degree of involvement, and for determining independently of the patient's report whether or not therapeutic measures have been successful. While occlusal therapy is still our most effective therapeutic measure, I believe it is apparent that we must use other aids in some of these cases. For example, I have used 2 per cent Novocain as a therapeutic aid and to help differentiate the psychogenic cases. In some, I got a cure unexpectedly, i.e., relief from pain. More recently, I have used hyaluronidase, and Hydrocortone in well-selected cases. I feel that injection therapy can be an important adjunct, but it should not be used empirically. I have presented only the core of a differential diagnostic technique which has been guided by my early dissections. Many phases of this outline can be developed more extensively. I have found this approach to be very satisfactory, and without the confusion attending most discussions I have heard or read. Whenever a seemingly new symptom develops in a patient's temporomandibular joint problem, I have found the solution by thinking as directed in this article, and I have discovered the explanation in normal pathologic or physiologic terminology. I believe this to be an effective, concrete technique for diagnosing temporomandibular and periarticular disturbances.