Temporomandibular disorders

Management of chronic jaw pain in Paris 16

Understanding chronic jaw pain

Definition and epidemiology

Chronic pain of the temporomandibular joint (TMJ) is the second most common cause of chronic musculoskeletal pain after low back pain, affecting 6 to 9% of adults worldwide. It manifests as pain in the jaw and associated structures, as well as symptoms such as headaches, ear pain, noises or crepitus in the temporomandibular joint, and impaired mandibular function. Chronic pain is defined as pain that has been present for more than 3 months.

What are the causes?

• Temporomandibular dysfunction (disc displacement, osteoarthritis)
• Myofascial syndrome (bruxism, clenching): muscular overuse creating painful trigger points
• Direct or repetitive trauma (prolonged dental surgery, cervical or facial impact)
• Systemic inflammatory conditions (rheumatoid arthritis, spondyloarthritis) that may affect the TMJ

These sustained aggressions lead to central sensitisation: the nervous system lowers its nociceptive threshold and amplifies every stimulus. On top of this biological basis, psychological and social factors are added: stress, anxiety, depression, work overload, disturbed sleep or lack of social support.

Symptoms of jaw pain

• Pain in front of the ear
• Pain in the jaw
• Pain in the masticatory muscles
• Headaches
• Joint noises (clicking, grating)
• Limited mouth opening
• Tinnitus

DC/TMD: definition and classification

The international reference framework for diagnosing these conditions is the DC/TMD (Diagnostic Criteria for Temporomandibular Disorders), published in 2014 by an international consortium led by Schiffman and Ohrbach. In France, the same conditions are historically named SADAM (Syndrome Algo-Dysfonctionnel de l'Appareil Manducateur). The abbreviation TMJ refers only to the joint itself, not to the disorder.

The DC/TMD sorts these disorders into three main clinical categories:

• Muscular disorders — myofascial pain of the masticatory muscles (masseter, temporalis, pterygoids), reproduced on palpation or contraction. This is the most common presentation in osteopathic practice.
• Intra-articular disorders — disc displacements with or without reduction, arthralgia, TMJ osteoarthritis. Suggestive signs: clicking, catching, transient locking.
• Mixed disorders — the two presentations coexisting in the same patient.

The DC/TMD adds a second axis assessing psychological factors (anxiety, depression, catastrophising), reflecting the biopsychosocial framework endorsed by the BMJ 2023 clinical practice guideline.

Key clinical signs and red flags

Certain findings point towards a TMJ disorder and help calibrate the treatment plan:

• Preauricular pain — located just in front of the tragus, worsened by chewing or forced opening.
• Limited mouth opening — the DC/TMD retains an interincisal opening of 40 mm as the international clinical cutoff. Below this value, opening is considered restricted.
• Joint noises — clicking (often linked to a reducible disc displacement) versus crepitus (more consistent with an osteoarthritic process).
• Open lock or closed lock — brief or persistent episodes of blocked jaw movement, distinct from ordinary morning stiffness.
• Referred pain — otalgia with no ENT abnormality, temporal headache, upper neck pain, sensation of a blocked ear.

Some findings require medical assessment before any manual therapy is started: sudden complete open lock, associated dysphagia, unexplained weight loss, fever, history of head and neck cancer. These situations fall outside the scope of osteopathy and should be referred to a physician.

Jaw, neck and headaches: the dysfunctional chain

Patients with TMD often report upper neck pain and headaches alongside their jaw symptoms. This is not a coincidence: it reflects a precise neuroanatomical convergence.

Sensory afferents from the trigeminal nerve (innervating the jaw, face and part of the skull) and those from the upper cervical nerve roots (C1, C2 and C3) converge on a common relay in the brainstem: the trigeminocervical nucleus. This convergence, described anatomically by Bogduk in 1992, provides the neurophysiological basis for cervicogenic headache.

Clinically, Fernández-de-las-Peñas and colleagues showed in 2010 that women with myofascial TMD present active trigger points both in the masticatory muscles (temporalis, masseter) and in the upper neck muscles (upper trapezius, sternocleidomastoid, suboccipitals). The referred pain areas of these trigger points cover precisely the regions where patients report their headaches.

The practical consequence is direct: treating only the jaw in a patient who also has neck tension amounts to addressing only part of the system. The osteopathic approach assesses and treats the whole cervical-cephalic chain, which explains why improvement in the jaw is often accompanied by a reduction in headaches and in the sensation of ear fullness.

Treatment of chronic jaw pain

The latest recommendations published in the BMJ (British Medical Journal) in December 2023

Strong recommendations in favour:

• Cognitive behavioural therapy (CBT)
• Passive mobilisations of the joint
• Postural exercises
• Exercises and stretches of the TMJ muscles
• Trigger point therapy
• Usual care

Conditional recommendations in favour:

• Manipulation
• Non-steroidal anti-inflammatory drugs + CBT
• Acupuncture
• Exercises + joint mobilisations

Treatment with osteopathy and manual therapy in Paris 16

This management fits into our overall approach to chronic musculoskeletal pain.

Scientifically proven efficacy of osteopathic treatment

Osteopathy and manual therapy are approaches that have scientifically demonstrated their efficacy in the management of chronic jaw pain, and have shown a significant reduction in pain and an improvement in patients' quality of life. Osteopathic techniques include specific and safe manual techniques to release the muscles of the temporomandibular joint, as well as those of the neck.

Mr Charbel Jean Kortbawi DO, MSc, osteopath specialising in pain management, treats acute and chronic pain of the temporomandibular joint at his practice in Paris 16.

Osteopath, dentist, orthodontist: who does what?

The BMJ 2023 guideline for TMD stresses multimodal, coordinated care. Each professional addresses a distinct component of the problem:

• The dentist — assesses occlusion, screens for infectious foci, prescribes an occlusal splint (useful in confirmed bruxism), and treats caries or periodontal disease that may sustain the pain.
• The orthodontist — intervenes when the dysfunction is structurally linked to significant malocclusion (marked class II, anterior open bite, transverse discrepancy), usually after prior dental assessment.
• The osteopath — treats the muscular component (masseter, temporalis, pterygoid tension), functional TMJ mobility, and the associated cervical chain. Pain education and postural advice are part of the same visit.
• The psychologist (CBT) — indicated when stress, anxiety or catastrophising sustain the bruxism and pain; a strong BMJ 2023 recommendation.

These approaches do not compete. They work better together, and single-lane care often misses what keeps the pain going in the longer term.