Disorders of the Jaw: Temporomandibular Disorders

Disorders of the Jaw

Abnormal conditions affecting the mandible (jaw) and of the temporomandibular joint (which connects the mandible to the temporal bone at the side of the head in front of the ear) include congenital malformation, fracture, chronic dislocation, cancer, and syndromes characterized by pain and limited motion. Tem-poromandibular disorders and jaw surgery (a treatment common in many structural abnormalities or cancer of the jaw) are presented in this section.

TEMPOROMANDIBULAR DISORDERS

Temporomandibular disorders are categorized as follows (Na-tional Oral Health Information Clearinghouse, 2000):

•        Myofascial pain—a discomfort in the muscles controlling jaw function and in neck and shoulder muscles

•        Internal derangement of the joint—a dislocated jaw, a dis-placed disc, or an injured condyle

•        Degenerative joint disease—rheumatoid arthritis or osteo-arthritis in the jaw joint

Diagnosis and treatment of temporomandibular disorders re-main somewhat ambiguous, but the condition is thought to affect about 10 million people in the United States. Misalignment of the joints in the jaw and other problems associated with the ligaments and muscles of mastication are thought to result in tissue damage and muscle tenderness. Suggested causes include arthritis of the jaw, head injury, trauma or injury to the jaw or joint, stress, and malocclusion (although research does not support malocclusion as a cause).

Clinical Manifestations

Patients have pain ranging from a dull ache to throbbing, debili-tating pain that can radiate to the ears, teeth, neck muscles, and fa-cial sinuses. They often have restricted jaw motion and locking of the jaw. They may hear clicking and grating noises, and chewing and swallowing may be difficult. Depression may occur in response to these symptoms.

Assessment and Diagnostic Findings

Diagnosis is based on the patient’s subjective symptoms of pain, limitations in range of motion, dysphagia, difficulty chewing, difficulty with speech, or hearing difficulties. Magnetic reso-nance imaging, x-ray studies, and an arthrogram may be per-formed.

Management

Although some practitioners think the role of stress in tem-poromandibular joint (TMJ) disorders is overrated, patient education in stress management may be helpful (to reduce grinding and clenching of teeth). Patients may also benefit from range-of-motion exercises. Pain management measures may in-clude nonsteroidal anti-inflammatory drugs (NSAIDs), with the possible addition of opioids, muscle relaxants, or mild anti-depressants. Occasionally, a bite plate or splint (plastic guard worn over the upper and lower teeth) may be worn to protect teeth from grinding; however, this is a short-term therapy. Con-servative and reversible treatment is recommended. If irreversible surgical options are recommended, the patient is encouraged to seek a second opinion.

SURGICAL MANAGEMENT

Correction of mandibular structural abnormalities may require surgery involving repositioning or reconstruction of the jaw. Sim-ple fractures of the mandible without displacement, resulting from a blow on the chin, and planned surgical interventions, as in the correction of long or short jaw syndrome, may require treatment by these means. Jaw reconstruction may be necessary in the aftermath of trauma from a severe injury or cancer, both of which can cause tissue and bone loss.

Mandibular fractures are usually closed fractures. Rigid plate fixation (insertion of metal plates and screws into the bone to approximate and stabilize the bone) is the current treatment of choice in many cases of mandibular fracture and in some mandibu-lar reconstructive surgery procedures. Bone grafting may be per-formed to replace structural defects using bones from the patient’s own ilium, ribs, or cranial sites. Rib tissue may also be harvested from cadaver donors.

Nursing Management

The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake.

PROMOTING HOME AND COMMUNITY-BASED CARE

The patient needs specific guidelines for mouth care and feeding. Any irritated areas in the mouth should be reported to the physi-cian. The importance of keeping scheduled appointments for as-sessing the stability of the fixation appliance is emphasized.

Consultation with a dietitian may be indicated so that the pa-tient and family can learn about foods that are high in essential nutrients and ways in which these foods can be prepared so that they can be consumed through a straw or spoon, while remain-ing palatable. Nutritional supplements may be recommended.