Temporomandibular Disorders in Children and Adolescents, Including Those with Special Health Care Needs

Board takeaway

Assess the temporomandibular joint (TMJ), chewing muscles, and jaw function before choosing treatment.

• A painless click often needs explanation and reassurance; pain, locking, altered function, bite change, or suspected systemic disease needs a focused assessment.
• Screen at each comprehensive examination, identify the pain source, and favor reversible care aimed at comfortable function and quality of life.

Decision map: screen, identify the source, then treat

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Painless clicking does not automatically need treatment. Conversely, absent pain cannot exclude JIA-related TMJ disease. Use imaging for the clinical question and retain a diagnosis-led, reversible treatment plan.

Definition, frequency, and evidence

• TMD encompasses musculoskeletal and neuromuscular conditions involving the TMJ, chewing muscles, and associated structures.
• Prevalence estimates vary with populations, examination methods, and diagnostic criteria; prevalence generally rises with age and is higher in females. Evidence below age nine is sparse.
• Original DC/TMD criteria were designed for patients over 18; adaptations address children ages 6–9 and adolescents ages 10–19.
• Headache may coexist with TMD or be attributed to TMD; these are distinct possibilities. Headache often precedes adolescent jaw pain.
• No single cause reliably predicts TMD. Adolescent TMD pain is associated with approximately threefold risk of pain in young adulthood.
• The source combines literature review with expert/consensus guidance where evidence is insufficient. Treatment reviews disagree; established pediatric evidence-based strategies remain limited.

Contributing factors and special health care needs

Trauma and loading

• Macrotrauma: chin impacts, direct mandibular injury, dislocation, or procedural hyperextension may injure masticatory structures.
  • Consider accompanying concussion.
  • Prolonged fracture immobilization can lead to ankylosis; fractures during growth may produce asymmetry.
  • A direct TMD relationship with whiplash remains unproven.
• Microtrauma: clenching, grinding, nail biting, and prolonged wind-instrument use may load the system.
  • Evidence linking parafunction to TMD is inconsistent; one review associated awake bruxism with painful pediatric TMD, but not sleep bruxism.
• Sleep bruxism is common in childhood and decreases with age.
• Its co-occurrence with sleep breathing disorders does not establish mechanism or temporal causation.
• Neurologic conditions such as spastic cerebral palsy increase parafunctional habits and bruxism.

Occlusion and orthodontics

• Occlusion/anatomy: associations are weak.
  • Reported associations include skeletal open bite, steep articular eminence, overjet greater than 6–7 mm, Class II profile, Class III malocclusion, and unilateral/functional posterior crossbite.
  • These are not treatment thresholds.
• Orthodontics has not been shown to cause or improve TMD, including with premolar extraction.
• Occlusal findings may be consequences of disease.
• Most children adapt to altered vertical dimension; a Hall-crown cohort found no TMD over 12 months.

Psychosocial and systemic factors

• Psychosocial: anxiety, depression, somatization, catastrophizing, stress, fear of movement, sleep dysfunction, family support, access, and stigma may influence symptoms/prognosis.
  • Psychological therapy alone has limited supporting evidence.
• Systemic/developmental: JIA, lupus, and psoriatic arthritis can affect the TMJ.
  • Many children with JIA have imaging evidence of degeneration without pain.
  • Hypermobility syndromes, including Ehlers-Danlos and Marfan syndromes, are associated with TMD; consider condylar developmental abnormalities and tumors.
• Genetic and biochemical associations are under study; no specific TMD biomarker exists. Estrogen's causal role is uncertain. Neck dysfunction may coexist, but posture alone does not establish TMD.

For JIA-specific surveillance, current medical treatment, and medication-related dental planning, see the juvenile idiopathic arthritis review.

Screening and focused diagnosis

• Ask about opening difficulty, joint sounds, ear/cheek pain, pain with chewing/talking/yawning, unusual bite, locking/dislocation, prior head/neck/jaw injury, and previous TMD care.
• Record pain location, timing, and characteristics. Screen by palpating masticatory muscles and lateral TMJ capsules, listening/palpating for sounds, and checking mandibular motion.
• With positive findings: assess associated muscles, document sounds, analyze occlusion, and record active/passive opening.
• Source indicators of limited interincisal opening: children < 32 mm; adolescents < 36 mm; adults < 40 mm. Chronic jaw pain is >3 months. Interpret findings within the full diagnostic assessment.
• Look for locking/catching, altered opening pattern, tenderness, fatigue, and muscle tension. Wear, tongue scalloping, mucosal ridging, and mobility may inform parafunction assessment.
• Exclude mimics: odontogenic, sinus or ear disease; primary headache; parotid disease; neoplasia; cervical dysfunction; Eagle syndrome. Ancillary testing is conditional on clinical need.

Diagnostic categories

• Joint: arthralgia; disc displacement with/without reduction; fibrous/bony ankylosis; adhesions; subluxation/dislocation; degenerative or systemic arthritis; osteonecrosis; ligament laxity; aplasia, hypoplasia/hyperplasia; tumors.
• Muscle: local, referred, or centrally mediated myalgia; tendonitis/myositis; spasm; contracture; parafunctional hypertrophy; tumors.
• Other: TMD-related headache/chronic orofacial pain, movement disorders, condylar/subcondylar fractures, and chronic primary pain.

Choose imaging for the question

• Imaging is recommended when pain appears primarily joint-derived, crepitation is present, or the bite changes. Other indications include new joint sounds, trauma/asymmetry assessment or monitoring, and failure of conventional treatment.
• Panoramic: gross bony findings; a normal image cannot exclude degenerative disease. Limited assessment of fossa/eminence; no evaluation of soft tissues, joint space, or condylar motion.
• CBCT: sensitive assessment of bony abnormalities, with more radiation than panoramic imaging.
• MRI: disc position/contour and soft tissues; open- and closed-mouth views assess the disc. Contrast-enhanced MRI evaluates inflammation and active degeneration and is the source's gold standard for JIA assessment.
• Ultrasound: superficial lateral joint assessment; less capable than MRI of identifying active synovitis.

Reversible treatment, reassessment, and referral

Choose conservative care

• Acute TMD often responds to education and analgesics such as NSAIDs; early care may reduce chronic-pain risk. Chronic TMD may need coordinated physical, behavioral, and pharmacologic care.
• Anti-inflammatory medication suits joint inflammation/arthritis; physical therapy may offer greater benefit for muscular TMD.
• Education: explain the condition, contributing factors, options, and goals.
• Behavioral options include habit awareness/reversal, relaxation, biofeedback, CBT, less excessive hard-food/gum chewing, adequate uninterrupted sleep, and care for behavioral comorbidity.
• Physical modalities listed include exercises, massage, mobilization/distraction, thermal measures, TENS, ultrasound, iontophoresis, and dry needling; inclusion does not establish equal pediatric efficacy.
• Pharmacologic options include NSAIDs, anxiolytics, and muscle relaxants.
• Opioids are not indicated for chronic TMD. Pediatric evidence for antidepressants used in adult orofacial pain is lacking.
• Obtain medical consultation for advanced or prolonged medication management.

Splints, response, and referral

• Stabilization splints temporarily alter occlusion/provide stability, usually at night.
• Hard or soft acrylic appliances cover a maxillary or mandibular arch; balanced appliances contact all teeth in a stable physiologic jaw position.
• Growth and erupting teeth complicate mixed-dentition use.
• Track pain, opening, jaw function/movement, and quality-of-life impact. The source specifies no fixed recall interval. Consider imaging for persistent nonresponse or evolving asymmetry.
• Refer when diagnosis or treatment exceeds competence: TMD expertise, oral surgery, behavioral health, or pain management.
• Arthrocentesis, injections, blocks, acupuncture, and off-label botulinum toxin are discussed from adult studies; do not assume established pediatric benefit.

Irreversible care

• Avoid irreversible treatment generally; reserve consideration for a last option.
• Occlusal adjustment/restorative alteration and orthodontics solely to prevent or treat TMD lack support.
• Surgery is limited to severe degeneration/destruction following trauma or tumor resection.

Common board traps

Answer aloud

How should you assess painless jaw clicking in an adolescent?

Screen and examine first; painless disc displacement with reduction generally needs explanation and reassurance.

• Ask about pain, locking, trauma, bite change, and functional limitation; examine the joint, muscles, and jaw movement.
• New sounds or other positive findings can justify further assessment. Choose imaging to answer the clinical question rather than ordering it for every painless click.

A child with juvenile idiopathic arthritis denies jaw pain. Does that exclude TMJ disease?

No. Juvenile idiopathic arthritis (JIA) can affect the temporomandibular joint without pain.

• Assess jaw function and facial growth; coordinate with the medical team.
• Contrast-enhanced MRI evaluates active inflammation and is the source's gold standard for JIA assessment.
• A painless examination or normal panoramic image cannot exclude joint disease.

Persistent muscular jaw pain has not improved. What changes?

Reassess the diagnosis and coordinate reversible treatment; refer when needs exceed your competence.

• Review pain source, function, dental/ear disease and other mimics, habits, sleep, psychosocial contributors, and response to prior care.
• Consider physical and behavioral approaches alongside appropriate medication.
• Track pain, opening, daily function, and quality of life; imaging may be needed for nonresponse or evolving asymmetry.
• Opioids are not indicated for chronic TMD. Irreversible occlusal correction lacks support.

Which findings make TMJ imaging useful, and which modality answers the question?

Image joint-derived pain, crepitation, bite change, or other findings requiring structural assessment.

• Other indications include new sounds, trauma, developing asymmetry, and failure of conventional treatment.
• Panoramic imaging shows gross bone changes but cannot exclude degeneration.
• CBCT assesses bone; MRI assesses disc and soft tissues, with contrast when evaluating active inflammation.