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Facial Pain - Tempormandibular Disorder
Speaker Key
RM Roddy McMillan
IV Interviewer
RM Hi, I'm Roddy McMillan. I'm consultant in oral medicine and facial pain at
Eastman Dental Hospital which is part of UCLH. My talk today was on pain-related
temporomandibular disorders, what we call TMD.
What is TMD?
RM Pain-related TMD is effectively pain affecting the temporomandibular joint and
the associated muscles. So classically, it's going to affect the joint itself, which is
either side in front of the ear, can spread from the temporal area down to the angle of
the jaw and also can occasionally recruit muscles in the neck and shoulders. The key
point is that there is no associated underlying significant joint pathology such as
arthritis or mechanical joint problems and no associated other pathologies such as
dental troubles. The pain can be acute. In other words, majority of patients who get
this problem, about 80% will have pain that will last for a few days or a few weeks.
20% of people, it tends to be more of a longer term problem.
Risk factors for developing TMD, classically, would be stress, anxiety, depression,
sleep disturbance, chronic pains in other parts of the body such as conditions like
fibromyalgia, irritable bowel syndrome, or lower back pain, for that matter, and
headaches. Very commonly associated is migraine, with this particular condition.
How is it diagnosed?
RM TMD is diagnosed from the history alone. There aren't really any scans or
investigations that one can conduct that will help to confirm the diagnosis. So anyone
with a history of pain in the muscles of mastication, possibly spreading into the neck
and shoulders, without any other identifiable cause of that pain, would be an
appropriate diagnosis. If somebody presents over the age of 50 with lateral facial pain
particularly affecting the temporal or the angle of the jaw area, then giant cell arthritis,
or better known as temporal arthritis, is possibly a diagnosis to exclude, and one could
potentially consider conducting an ESR or a CRP, because if those blood tests are
negative, then they're highly unlikely going to have diagnosis of giant cell arthritis.
Are there any treatments possible in primary care?
RM The good thing about TMD is 80% of people who present with acute TMD will
get better within a few days or a few weeks without any significant treatment. So
simple discussion about the condition, some reassurance if possible, perhaps some
analgesics, and that's probably all that's required initially.
About 20% of people it tends to be more of a longer term problem. These tend to be
patients with comorbidities such as anxiety, depression, sleep problems, and chronic
pains in other parts of the body. Also, migraines are involved there. And those
patients may well require some support in terms of perhaps a referral for
physiotherapy, for some education and physiotherapy exercises that the patient can
conduct at home, or they may benefit from medications. The types of medications we
tend to use initially as a first line would be standard chronic pain medications,
prescriptions such as amitriptyline or nortriptyline would be appropriate in this case.
Psychology is something which can be used, but that tends to be more of a secondary
care measure, and we would normally recommend it if the initial treatments are not
working. Then you would probably be best to refer into a secondary care facial pain
When should a GP refer on?
RM Generally, as I said earlier, 80% of people get better without any significant
intervention. So for the people that don't tend to respond to simple measures and have
prolonged pain lasting longer than a three month duration, then certainly they should
be referred into a secondary care pain management setting or a facial pain clinic.
People that we would be happy to see in secondary care sooner than that three-month
period would be people with significant comorbidities such as anxiety, depression,
sleep disturbance, and chronic pains in other parts of the body. These patients tend to
be the ones that are more likely to develop chronic pain, and therefore it would be
appropriate in those circumstances to refer them a little bit sooner than the threemonth period.
Which specialist or specialist service do GPs refer to?
RM In terms of TMD, there's probably quite a selection of different services one can
refer to. I would suggest, initially, if you are within easy reach of an oral medicine
unit in one of the dental teaching hospitals, then a referral to one of those services
would be appropriate. There are very few specialist facial pain services in the UK, but
one service is based at the facial pain service within UCLH in London, and we'd be
happy to receive referrals.
The local oral and maxillofacial surgery or oral surgical services can see these patients
who are perhaps developing more of a mechanical problem with the jaw, such as
difficulty opening the mouth wider, significant deviation when they open the mouth
wide. If you don't have ready access to an oral medicine unit or a facial pain service
locally, then the oral maxillofacial surgeons probably would be the next best thing.
What is the management in secondary care?
RM The management of TMD generally in secondary care would be more chronic
TMD patients. So these patients follow similar sort of patterns in terms of their
management compared to other chronic pain conditions. So we would normally break
that into the three pillars of pain management.
The first pillar of pain management being vitally important, and that is regular
physical exercises and relaxations conducted by the patient themselves at home.
Things like swimming, walking, yoga, tai chi, meditation or Pilates. Some other
physical aspects of treatment can be physiotherapists. So physiotherapy can be
involved, although it tends not to be hands-on physiotherapy, more direction of the
patient towards exercising themselves. Another physical therapy would be
acupuncture, which has got a small amount of scientific evidence to say it's useful in
Moving on from that, the second pillar of pain management is medications. The types
of medications we briefly talked about earlier. Generally, the first line treatments
would be tricyclic antidepressants such as amitriptyline or nortriptyline. The reality is,
there's very little in the way of really highly effective medications for the management
of chronic pain, specifically TMD in this case.
The third pillar of pain management is clinical psychology, and as with many other
chronic pain conditions, clinical psychology can be very, very helpful in terms of
enabling the patient to self-manage their condition and reduce the negative impact that
the pain's having on their quality of life in spite of the pain being present there in the
What is the prognosis?
RM The prognosis of TMD is quite variable. At least 80% of patients who develop
acute TMD will get better and dissipate on its own. Around about 20% of patients
tend to have more prolonged symptoms. So either the pain is there all the time or it's
there more frequently than not. In terms of the condition itself, we cannot promise
patients that, with chronic TMD, that we'll be able to give them any treatments that
will completely remove all of the symptoms... in other words, cure their pain. But we
certainly can help them to self-manage their condition and to improve their quality of
life in spite of the pain being present in the background.
Where can GPs find out more?
RM GPs can find out quite a bit of information on the Eastman Dental Hospital
facial pain website. This is part of the main UCLH website and can be found quite
easily on the internet. This has a lot of facilities on it, including details on how to
contact the department and refer patients. And also, it has patient information leaflets
and advice sheets that can be downloaded and given out to patients in primary care.