Clinical diagnosis and treatment of temporomandibular disorders in children

Clinical diagnosis and treatment of temporomandibular

disorders in children and adolescents: a case series

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Won Jung*/ Dae-Woo Lee**/ Yeon-Mi Yang***

The early diagnosis of temporomandibular disorders (TMDs) in children and adolescents is im-
portant because they can affect oral and maxillofacial growth and development. This case series
introduces patients with various clinical features of TMDs and demonstrates how symptoms were
reduced through appropriate interventions in collaboration with oral medicine specialists and
pediatric dentists. TMDs symptoms in children are often mild and difficult to express accurately;
therefore, diagnosis through clinical evaluation is important. Pediatric dentists should be aware
of TMDs in children and adolescents, and should diagnose, treat, and refer to specialists in a
timely manner.

Keywords: Temporomandibular joint dysfunction syndrome, Arthritis, Juvenile, Myalgia

INTRODUCTION
emporomandibular joint disorders (TMDs) is an um-

T brella term that refers to diverse problems in the mas-

ticatory system 1 . Pain in the masticatory muscles,
preauricular area, or temporomandibular joints (TMJs) is the
most common symptoms of TMDs. In addition to pain, vari-
ous other clinical symptoms can occur, such as limited open-
ing, deviation of mandibular movement, TMJ dysfunction,
and clicking sounds 1,2 .
The prevalence of TMDs has been widely reported, rang-
ing from 4.2% to 88%. Women are predisposed to the con-
dition, and the prevalence of signs and symptoms increases
with age 1,3–5 . In children and adolescents, the prevalence of
TMDs diagnosed according to the Research Diagnostic Crite-
ria for TMD (RDC/TMD) or the Diagnostic Criteria for TMD
(DC/TMD) ranges from 7.3% up to 30.4% 6,7 .
The etiology of TMDs is as diverse and multifactorial as the
From the Jeonbuk National University and Research Institute of Clinical various symptoms. There is no single etiology that explains
Medicine of Jeonbuk National University-Biomedical Research and all symptoms. Several local systemic factors such as occlusal
Institute of Jeonbuk National University Hospital, Jeonju, Republic condition, trauma, emotional stress, deep pain, parafunctional
of Korea.
* activity, and systemic diseases could interact to trigger TMD
Won Jung, DDS, PhD, Assistant Professor, Department of Oral
Medicine, School of Dentistry. signs and symptoms 1,8 . Similarly, in children and adoles-
**
Dae-Woo Lee, DDS, PhD, Associate Professor, Department of cents, macro-trauma, parafunctional habits, psychosocial fac-
Pediatric Dentistry, School of Dentistry. tors, and systemic factors have been reported as etiologies of
***
Yeon-Mi Yang, DDS, PhD, Professor, Department of Pediatric TMDs 9 .
Dentistry, School of Dentistry.
TMDs can be classified in various ways based on diag-
Corresponding Author: nostic criteria. According to the DC/TMD, which provides
Yeon-Mi Yang, reliable evidence-based criteria, it can be classified as myal-
Department of Pediatric Dentistry and Institute of Oral Bioscience, gia, arthralgia, disc displacement, or a degenerative joint dis-
School of Dentistry, Jeonbuk National University, 567, ease. To diagnose for TMDs, history-taking, examination, and
Baekje-daero, Deokjin-gu, Jeonju-si, Jeollabuk-do,
561-712, Republic of Korea. imaging procedures are necessary. In clinical, history-taking
Phone: +82-63-250-2128 of the present illness is important to identify the contributing
E-mail: [email protected] etiological factors. History-taking should include the follow-

This is an open access article under the CC BY 4.0 license. doi: 10.22514/jocpd.2022.029
J Clin Pediatr Dent 2022 vol.46(6), 63-67 ©2022 The Author(s). Published by MRE Press. https://www.jocpd.com 63
Clinical diagnosis and treatment of temporomandibular disorders in children

ing: onset of pain, behavior-associated pain, pain intensity, The patient wore the OSA while sleeping, and there were
parafunction, psychosocial factors, TMJ locking history, joint no associated adverse side effects. After 3 months of treat-
noise, and limitation severe enough to interfere with the abil- ment, the TMJ pain was alleviated; after 6 months, the
ity to eat. A clinical examination should include palpation mouth-opening limitation was relieved. She received ongo-
of muscles or TMJ and evaluation of signs of TMDs, such ing follow-up care.
as opening movements, lateral or protrusive movement, and

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clicking or popping noise present with jaw movements. A di-
agnosis of DC/TMD based on a clinical examination should
be supported by the results of appropriate imaging modali-
ties 10–12 .
The successful management of TMDs is dependent upon
appropriate diagnosis and control of these etiological fac-
tors 10 . Therefore, an appropriate diagnostic and therapeutic
approach through clinical and radiographic examinations is
important 1 . The goal of treatment for TMDs in children and
adolescents is to recover their quality of life through pain relief
and restoration of TMJ function 13,14 . However, as symptoms
are often mild and a child’s expression of them can be inaccu-
rate, diagnosis is often difficult in children and adolescents 15 .
This report introduces three different cases of TMD that were
diagnosed and treated.

CASE REPORTS
Case 1
An 11-year-old boy with no significant medical or den-
tal history was referred to the Department of Oral Medicine
at Jeonbuk National University Hospital from a local dental
clinic because of a painless loss of strength during chewing. Figure 1: Panoramic temporomandibular joint
On presentation, the child complained of “loss of muscle (TMJ) radiograph showing no remarkable
strength” when eating meals. There was no discomfort while pathological findings in either TMJ in an
eating his favorite snacks. Clinical examination revealed pain 11-year-old boy diagnosed with myalgia.
on palpation of the masseter and temporalis muscles. There
were no joint sounds or mouth opening limitation. Panoramic
radiographs showed no remarkable pathological findings in
either TMJ (Fig. 1).
The child was diagnosed with myalgia based on the
DC/TMD. He was treated using conservative modalities, in-
cluding physical and behavioral therapy. Physical therapy was
administered twice a week, and his discomfort began to im-
prove after 3 weeks. After 6 weeks of treatment, the muscle
weakness disappeared.

Case 2 Figure 2: Magnetic resonance imaging of

A 13-year-old girl visited the clinic with left TMJ pain dur- 13-year-old girl with left TMJ pain during mouth
ing mouth opening that had started a month previously. Her opening. Sagittal oblique proton density image shows
medical and dental histories were unremarkable, except for a anteriorly displaced disc (arrow) of the joint (arrowhead)
few dysfunctional habits (clenching and chin leaning). in the (A) closed and the (B) open mouth state.
Clinical examination revealed limited mouth opening (32
mm) with left TMJ pain and leftward deflection on opening.
Additionally, the maximum assisted opening was also limited Case 3
(33 mm). There was no history of joint sounds, but the impres- A 5-year-old child visited our clinic with trauma to the max-
sion was a disc displacement without reduction (DDWoR). illary primary teeth. Panoramic radiography revealed asymp-
Magnetic resonance imaging (MRI) was performed to confirm tomatic bony destruction of the left condyle. Cone-beam com-
this impression. MRI showed that the discs of both TMJs were puted tomography (CBCT) revealed extensive erosion of the
displaced anteriorly in both the open and closed states (Fig. 2). left condyle (Fig. 3).
We provided the patient with an occlusal stabilization appli- Clinical examination revealed limited mouth opening and
ance (OSA) and administered behavioral and physical ther- leftward deflection on opening. Her medical history was sig-
apy. nificant for juvenile rheumatoid arthritis 3 years previously.

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 Clinical diagnosis and treatment of temporomandibular disorders in children

Extensive erosion of the left condyle was thought to be asso- al. 16 reported that the quality of evidence in pediatric dentistry
ciated with systemic rheumatoid arthritis. The child was pro- research related to orofacial pain is weak and limited.
vided with an OSA to stabilize the condyle. Considering the Children often do not accurately express their discomfort.
mixed dentition, a temporary OSA was selected with subse- It has been reported that TMD symptoms in children are rare
quent replacement of the appliance according to tooth eruption and variable compared to adults. Moreover, the children do
(Fig. 4). She was also referred to a pediatric rheumatologist not clearly explain these symptoms 14 . In this case report, only

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for systemic control. one child accurately expressed her discomfort. Pain is a sub-
The child has adapted well to the OSA, which is constantly jective sensation, and individuals learn to apply appropriate
being replaced according to the eruption of the child’s perma- words to express pain through childhood pain experiences 17 .
nent teeth. Follow-up care is ongoing. Pain assessment in children is difficult for various reasons,
including the subjective and complex nature of pain and chil-
dren’s limited language for expressing pain 18 . In Case 1, we
considered the possibility that the atypical symptom of losing
strength expressed a feeling of muscle weakness accompanied
by mild pain. A feeling of muscle weakness may appear with
muscle pain and dysfunction in various masticatory muscle
disorders, such as local muscle soreness and protective co-
contraction 13,19,20 . In particular, protective co-contraction is
painless at rest but is reported clinically as a “feeling of muscle
weakness” and increased pain during muscle use 13 . Although
our patient did not complain of pain, “loss of muscle strength”
was inferred as a feeling of muscle weakness during function,
and pain was confirmed upon palpation of the bilateral mas-
seter and temporal muscles in clinical examination. The pa-
tient was diagnosed with myalgia according to the DC/TMD,
and his chief complaint disappeared after treatment. A thor-
ough history of the present illness is very important for the
accurate diagnosis of TMDs in children and adolescents.
Figure 3: Cone-beam computed tomography TMDs are associated with pain and dysfunction of the mas-
showing a large defect area and erosion of the left ticatory system and are a significant health problem in children
condyle in a 5-year-old child with trauma to the and adolescents 15,16 . As in Case 2, when a child shows lim-
maxillary primary teeth. ited opening, an accurate diagnosis of the cause is important.
On clinical examination, the maximum assisted opening test
is helpful for the diagnosis. If the maximum assisted open-
ing movement is less than 40 mm (including vertical incisal
overlap), clinical DDWoR with limited opening is considered
according to the DC/TMD. However, the diagnostic validity
of DDWoR in the DC/TMD showed a sensitivity of 0.80 and a
specificity of 0.97. Thus, the diagnosis needs to be confirmed
Figure 4: Occlusal stabilization appliance (OSA) using MRI 11 . In addition, cutoff values for jaw opening lim-
treatment of 5-year-old girl with rheumatoid itation in children and adolescents are different from those
arthritis. (A) Temporary OSA. (B, C) Five-year-old in adults. Müller et al. 21 reported the mean maximal mouth
child wearing the device. opening capacity (MOC) of healthy children in a retrospective
cross-sectional study; the mean age was 9.9 (3.3–18.3) years
for girls and 10.0 (2.8–18.7) years for boys. The mean MOC
DISCUSSION was 45 mm (25–69 mm in girls) and 45 mm (25–70 mm in
Accurate and early diagnosis is important for the success- boys), similar to that in adults. However, they showed a wide
ful treatment of TMDs 1 . However, various factors make di- MOC range when compared with children of the same age.
agnosis difficult in children and adolescents. The DC/TMD They suggested that the cutoff value for jaw opening limita-
suggests criteria for TMDs diagnosis according to objective tion in adolescents is 36 mm (third percentile at 10 years of
examination results that confirm the subjective functional lim- age). Accordingly, MRI may be helpful for accurate diagno-
itation or pain. The DC/TMD is the international standard for sis when the child complains of limited jaw opening.
the evaluating TMD and shows high diagnostic accuracy for Limited jaw opening due to DDWoR requires appropriate
TMD in adults 11 . Although the DC/TMD has been validated intervention. The prevalence of disc displacement is approx-
for adults with TMD, the use of the DC/TMD in children and imately 8.3% 6 . Macro-trauma can directly cause tissue in-
adolescents requires validation in each age group 15 . Insuf- jury. Persistent microtrauma can also result in ligament elon-
ficient comprehension of orofacial pain in children and ado- gation, leading to slow development of disc displacement 13,22 .
lescents is an obstacle to successful treatment 14 . Christidis et In addition to trauma, various mechanical and physiologi-

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Clinical diagnosis and treatment of temporomandibular disorders in children

cal factors such as abnormal stress or strain of the condyle jaw deformities, children with JIA have a higher prevalence of
and/or retrodiscal ligaments, muscle hyperactivity, and mal- orofacial pain, including headache, neck pain, and TMDs 33 .
positioning of the joint related to growth could cause dis- This suggests that early diagnosis and treatment of TMJ arthri-
placement 23,24 . DDWoR associated with persistent limited tis in children with JIA are important, and periodic TMJ ex-
jaw opening, TMJ pain, and degenerative joint disorder (DJD) amination is necessary. Studies on the preventive effects of
should be addressed appropriately. The prevalence of DJD, periodic TMJ examination on TMJ arthritis in patients with

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which can cause serious complications such as irreversible jaw JIA are still lacking. However, further research on this topic
asymmetry and condylar deformity, is higher in patients with is required.
DDWoR than in those with other types of TMDs 25,26 . In this case series, we report on pediatric patients with var-
We selected an OSA as the main treatment strategy for this ious types of TMD. The prevalence of TMDs in children and
patient (in Case 2). Although the treatment mechanism for the adolescents has been reported, but there is a lack of consen-
OSA remains unclear, OSA therapy is known to be a success- sus on its diagnosis and treatment 16 . TMDs can cause pain
ful treatment for patients with TMDs. The OSA could effec- in the masticatory system and related dysfunction, which can
tively reduce pain and increase the range of mouth opening adversely affect the quality of life of pediatric patients. How-
compared to other treatments. Previous studies provided evi- ever, compared to other oral diseases, their importance has
dence of that OSA treatment was effective and considered to been relatively under-emphasized, which has led to a lack of
have several treatment effects 13,27 . Inducing orthopedic sta- research on TMDs in children 15 . Therefore, it is necessary
bility and altering the functional relationships of the TMJ are for clinicians to be interested in TMDs in children and adoles-
believed to be the main effects. An OSA can also minimize cents. Clinicians should evaluate the signs and symptoms of
pathological load and protect tissues such as the condyle, TMJ TMDs during periodic checkups. A simple questionnaire con-
ligaments, masticatory muscles, and retrodiscal ligaments 13 . taining the following information may help screen the TMDs
It is thought that the reduction of pathological load, mainte- history of children: limitation of jaw movements, pain during
nance of a stable position of the TMJ, and protection of tis- eating, and joint sound. The range and path of mouth open-
sues gradually allow the condyle to perform normal transla- ing should be assessed during clinical examinations. Palpation
tion movement 27 . of the TMJ and temporalis and masseter muscles can be per-
formed to determine pain in the masticatory system. In addi-
Juvenile idiopathic arthritis (JIA) is the most common form tion, pathological findings such as cortical erosion, flattening,
of arthritis of unknown etiology in children under 16 years of and sclerosis of the condyle can be evaluated using radiolog-
age. In JIA, TMJs are commonly affected, but early diagnosis ical images 10–12 . It should be noted that the various types of
is difficult because most patients are asymptomatic. In fact, TMDs observed in adults can also occur in children 6,7 .
many patients with JIA present with significantly advanced
TMJ degeneration 28–30 . In Case 3, the child was also asymp-
tomatic and discovered incidentally during an examination af- CONCLUSIONS
ter trauma. Although her systemic arthritis was well managed, Because symptoms in children and adolescents are often
CBCT revealed extensive erosion of the left condyle. TMJ in- mild and difficult to express clearly, thorough clinical exam-
volvement in JIA can alter dentofacial development and lead inations are recommended for the early diagnosis of TMDs.
to many complications, such as malocclusion, asymmetry, mi- In addition, patients with risk factors such as parafunctional
crognathia, and facial deformity. In previous studies, mi- habits and systemic diseases should be carefully evaluated for
crognathia and malocclusion in children with JIA have been TMDs during periodic follow-up examinations. With interest
reported in 30% and 66% of children, respectively. These in the field of pediatric TMDs, various studies on the preva-
complications reduce these patients’ quality of life 29–31 . Ap- lence of TMDs and validation studies on the DC/TMD in chil-
propriate interventions are needed to minimize jaw deformity dren should be conducted.
and micrognathia in patient with JIA with TMJ involvement.
However, there is no consensus on the treatment for complete
remission of TMJ osteoarthritis in patients with JIA. Various FUNDING
treatment modalities, such as systemic medication, occlusal
This research received no external funding.
appliances, and intra-articular treatment have been suggested.
Unfortunately, the response of the TMJ to systemic medica-
tion may be poorer than that of other joints, and it is recom- ETHICS APPROVAL AND CONSENT TO
mended to limit intra-articular injection in children 32 . In Case
PARTICIPATE
3, the child was provided with an OSA to minimize the de-
struction of the condyle. As previously stated, using an OSA This study was approved by the institutional review board
is a successful treatment for TMDs patients. It also applies to of Jeonbuk National University Hostpital (IRB No: 2022-09-
osteoarthritis of the TMJ. When the OSA is in place, it can 039) and the written informed consent have been obtained
maintain the condyles in the most stable musculoskeletal po- from all participants (or the guardian) in this article.
sition 13 . Musculoskeletal stability of the condyle can mini-
mize condyle deformation and mandibular asymmetry caused
by TMJ inflammation. On follow-up, our patient showed no CONFLICT OF INTEREST
symptoms or pathological changes. In addition to possible The authors declare no conflict of interest.

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 Clinical diagnosis and treatment of temporomandibular disorders in children

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