Managing Sprains & Persistent Inflammation In The TMJs

Throughout the course of any given year my office is challenged by numerous patients who present with acute pain in their temporomandibular joints, limited jaw motion, and at times the inability to bring their teeth together properly. These scenarios often arise due to accidents that impact the jaw. 

Many of these patients experience lingering pain several weeks or months after the initial injury despite a typical regimen of care (dietary restrictions, NSAIDS and ice). Here are two recent cases of note:

Case #1 Sue

Sue is a 70-year old female. Six weeks prior to presenting for care she fell in her apartment and struck the left side of her jaw against a kitchen counter. Immediate pain in the left TMJ led to limited motion and an inability to bring her teeth together on the left side. 

Seven weeks of a soft diet, anti-inflammatory medication, and frequent ice application saw her jaw motion improve. However, acute joint pain was still present during eating and wide jaw opening efforts. In addition, her teeth were not fully meshed on the left side. 

A prior history of jaw problems was denied and there was no evidence of awake or sleep bruxism. My exam revealed exquisite point tenderness over the left TMJ, and guarded, sore jaw muscles. Jaw opening with pain was recorded at 32mm. The joint pain was worse when efforts were made to bring the teeth together.

A cone beam scan revealed no evidence of fracture, condylar degeneration or arthritic change.

Case #2 John

At 55-years old, John felt sharp pain and something give way in his left TMJ when he bit into a solid piece of chocolate that he thought was soft-centered. Despite subsequent eating caution and anti-inflammatory medication John continued to experience limited jaw motion, altered tooth contact on the left side and intense joint pain eight weeks after the event - particularly as he tried to fully mesh his teeth. 

My exam revealed marked point tenderness over the left temporomandibular joint, limited jaw motion measuring 33mm, muscle soreness, and incomplete tooth contact on the left side 

A cone beam scan again was unremarkable for osseous compromise.

Both of these cases represent scenarios where first-line treatment efforts can fall short after a single event prompts joint injury. At the time of presentation, both patients pointed directly to their temporomandibular joints as the area of concern. Combined with evaluation findings, a diagnosis of a traumatically induced joint inflammation process with effusion was made. A decision, therefore, had to be made to consider options that would address the joint inflammation more directly.

Steroid Injections

Based on a review of the literature regarding the management of small joint sprains and persistent inflammatory pain, there appears to be sufficient evidence to support injecting these symptomatic joints with a steroid. In both cases this direction of care was selected and 10mg of Kenalog (triamcinolone acetonide) was injected into the painful TMJs. This was after a diagnostic anesthetic injection eliminated a substantial part of the joint pain being experienced during jaw opening and closing movements. 

After the steroid was injected there was a resultant reduction of pain at a 70-80% level (based on visual analogue scale recordings) after one month and a cessation of pain after a second injection three months later in both cases. Full tooth contact was also achieved in both cases. No additional oral anti-inflammatory medications were taken after the steroid injections.

When considering the history of these injuries, the age of the patients, no prior problematic TMJ symptoms, unremarkable joint scans, and the acuteness of their symptoms, I believe this strategy of care had merit and continues to be considered when confronted with similar scenarios.

As repeated steroid injection is not advisable in the TM joints due to concern related to fibrocartilage integrity, if improvement did not occur after the first injection, an MRI scan would have been obtained to shed additional light on the joint injuries. In these two cases this did not prove to be necessary.

I welcome your commentary.