Arthritis of the Temporomandibular Joint

The temporomandibular joints (TMJ) are the points at which the lower jaw are attached to the skull, and are located on either side of the face.  The TMJs are small joints comprising of bones, muscles, blood vessels, and nerves.  It allows the mouth to open and close through its hinge action and to open wider through its gliding action.These joints move synchronously when a person speaks, chews and swallows.

This condition may result in TMJ syndrome characterized by pain in the jaw, head and neck, a jaw that is difficult to open or locked in position, and jaw popping or clicking. 

There are several types of arthritis which can affect the TMJ.

1. Osteoarthritis involves the degeneration of the cartilage within the TMJ, causing friction between the bones. This results in inflammation and joint pain.
2. Rheumatoid arthritis is a defect of the auto-immune system, in which the body itself attacks the cells of the TMJ, causing inflammation.
3. Infectious arthritis is inflammation caused by infection of the TMJ. Often, infection is carried through the bloodstream to the TMJ from another part of the body.

Pathophysiology

In osteoarthritis, there are arthritic or degenerative changes in the bone and cartilage due to aging.  There is a gradual but progressive loss of carticlage at the surface of the joint, with the formation of new bone.  Destruction of the cartilage may also ensue because of repetitive trauma. 

Rheumatoid arthritis causes symmetric joint inflammation and can result in destruction of the cartilage and bone erosion as the condition progresses, causing a deformity in the joints. 

Epidemiology

Individuals 50 years old and above are prone to develop osteoarthritis of the TMJ.  In patients with rheumatic arthritis, around 17% of them have TMJ involvement, however, it is among the last joints involved.

Clinical Features

The most common symptom is pain.  Pain may involve the facial muscles and jaw joints, radiating to the neck or shoulders; this is occasionally accompanied by swelling of the face and mouth.  There may also be ear pain.  There may be clicking or popping sounds heard from the joint, indicating that it may be in an abnormal position.  The jaw may not open fully or it may lock wide open and become dislocated.

During physical examination, there may be tenderness over the affected joint and limitation of motion of the lower jaw.

Diagnosis

Radiographs of the mouth and jaw may be taken.  MRI may be able to visualize the appearance of the TMJ.

Treatment

Treatment is usually conservative and symptomatic because most cases of TMJ syndrome are temporary.  Therapy may be jaw rest, warm compress, and pain medications.  A splint or bite plate may also be applied to ease muscle tension.  It is guard that fits over the upper and lower teeth to reduce clenching and teeth grinding.  Steroid injection can also alleviate the pain and inflammation.

If the condition is refractory, surgery may be performed.  The jaw joints may be replaced with artificial implants. 

Efficacy of Alternative and Other Treatments According to GRADE* Ranking:

Pau D'Arco (Lapachol, Tabebuia Impetiginosa, Tabebuia Heptaphylla) [1, 2]:

Please note, this treatment has potentially serious side effects. Some of the chemicals in the plant are known to be toxic. High doses are known to cause liver and kidney. Even at low doses, chemicals in the plant may interfere with blood clotting, causing excess bleeding and anaemia. Pau D'Arco should be avoided, especially by pregnant or breastfeeding women.

Recommendation: Strongly against (There is insufficient evidence to support claims that Pau D'arco helps to treat Arthritis. This, combined with its potentially harmful side effects if taken without supervision from a doctor or pharmacist gives enough reason to avoid this treatment.)

Grade of Evidence: very low quality of evidence

Neural Therapy:

Please note, this management does NOT treat the condition itself. It is proposed only as supportive symptomatic support, and even then, has insufficient evidence to back up this claim at present.

Recommendation: no recommendation (no reliable clinical studies have been done to support Neural Therapies role in reducing arthritis)

Grade of Evidence: very low quality of evidence

Heat Therapy:

Recommendation: weakly in favor (clinical studies have shown that Heat Therapy can help relieve symptoms of arthritis)

Grade of Evidence: low quality of evidence

Low-Level Laser Therapy:

Recommendation: no recommendation (There have been ambiguous results on the few studies done investigating the effect of laser therapy on arthritis)

Grade of Evidence: very low quality of evidence

Acupuncture:

Recommendation: weakly in favor (There is some evidence that suggest that Acupuncture may decrease the need for pain medication in arthritis)

Grade of Evidence: very low quality of evidence

Neuro-Linguistic Programming:

Recommendation: no recommendation (No reliable evidence exists supporting claims that Neuro-linguistic programming helps in treating arthritis.)

Grade of Evidence: very low quality of evidence

Craniosacral Therapy:

Recommendation: no recommendation (A few well-controlled trials have been performed, which state that successes in treating arthritis have not been found)

Grade of Evidence: low quality of evidence

* www.gradeworkinggroup.org

Summary References

Treatments:

1. Ades T, Alteri R, Gansler T, Yeargin P, "Complete Guide to Complimentary & Alternative Cancer Therapies", American Cancer Society, Atlanta USA, 2009

2. http://www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/HerbsVitaminsandMinerals/pau-d-arco