I have been diagnosed with TMD. According to a recent MRI, I have disc displacement and moderate joint degeneration. What are my treatment options?

Patient Question

Olivia Thompson 🇦🇺: Dr. Samuel, I’ve been experiencing jaw pain, limited opening, and occasional locking for about 8 months. After seeing several doctors, I was finally diagnosed with TMD. My recent MRI shows disc displacement without reduction in my left joint and moderate degenerative changes in both joints. I’m concerned about the degenerative findings and wondering what treatment options are available. Will I need surgery? Can the degeneration be reversed or at least stopped? I’m 42 and worried this will continue to get worse with age.

Dr. Rockson Samuel’s Response

Dr. Rockson Samuel: Thank you for sharing your concerns, Olivia. I understand how distressing temporomandibular joint disorder (TMD) symptoms can be, especially when coupled with imaging findings like disc displacement and degenerative changes. Let me address your questions and outline the available treatment approaches.

Understanding Your Diagnosis

First, let’s clarify what your MRI findings actually mean:

1. Disc Displacement Without Reduction:

   • This means the articular disc in your left TMJ has moved from its normal position and doesn’t return to place during jaw movement
   • This can explain the limited opening and locking sensations you’re experiencing
   • It’s more advanced than displacement with reduction (where the disc returns to position with a “click”)

2. Moderate Degenerative Joint Changes:

   • This typically refers to osteoarthritic changes including:
     • Flattening of the condyle (the rounded end of your jawbone)
     • Possible osteophyte formation (bone spurs)
     • Subchondral cyst formation or sclerosis (hardening of bone)
     • Changes to the articular eminence (the part of the temporal bone that forms the socket)
   • These changes are not uncommon, especially after age 40

Treatment Philosophy for TMD with Degenerative Changes

The good news is that the treatment approach for TMD has evolved significantly in recent decades toward more conservative management. Here’s what you should know:

1. Correlation Between Imaging and Symptoms:

   • Research shows that imaging findings don’t always correlate directly with symptoms
   • Many people with significant degeneration on imaging have minimal symptoms
   • Conversely, some with minimal imaging changes experience significant pain

2. Natural Course of Degenerative TMJ Disease:

   • TMJ degeneration often reaches a point of stabilization rather than continuing to worsen
   • The body develops adaptive mechanisms over time
   • Many patients experience improvement in symptoms even when structural changes remain

3. Treatment Goals:

   • Pain reduction and improved function are primary goals
   • Preserving existing joint structures
   • Managing contributing factors
   • Improving quality of life

Comprehensive Treatment Options

Treatment for TMD with degenerative changes typically follows a stepped approach:

1. Conservative (Non-invasive) Management

This is always the first line of treatment and includes:

a) Physical Therapy and Self-Care:

• Targeted exercises to improve jaw mobility and strength
• Posture training (especially head and neck position)
• Manual therapy techniques for muscle tension
• Heat/cold application protocols
• Self-massage techniques
• Controlled, gentle stretching exercises

b) Medication Management:

• NSAIDs (like ibuprofen) for inflammation and pain
• Muscle relaxants for acute muscle spasm
• Topical analgesics for localized pain
• Low-dose tricyclic antidepressants or SNRIs for chronic pain management

c) Occlusal Appliances (Splints):

• Stabilization splints to reduce joint loading and muscle activity
• Repositioning appliances in specific cases
• Night guards for associated bruxism
• These devices distribute forces more evenly and can decrease joint stress

d) Behavioral Modifications:

• Stress management techniques
• Sleep hygiene improvement
• Cognitive behavioral therapy for chronic pain
• Nutritional counseling (soft diet during flares, avoiding extreme jaw movements)
• Elimination of parafunctional habits (nail biting, gum chewing, etc.)

2. Minimally Invasive Procedures

If conservative measures provide insufficient relief after 3-6 months:

a) Trigger Point Injections:

• For associated myofascial pain
• Can provide significant relief for muscle-related symptoms

b) Arthrocentesis:

• Joint lavage (washing) under local anesthesia
• Removes inflammatory mediators
• Can break light adhesions
• Often combined with injection of corticosteroids or hyaluronic acid
• Minimally invasive procedure with good success rates

c) Botulinum Toxin Injections:

• For hyperactive muscles contributing to joint loading
• Temporary effect requiring periodic treatment
• Particularly useful when bruxism is a significant factor

d) Platelet-Rich Plasma (PRP) or Regenerative Injections:

• Emerging treatment showing promise
• May help with inflammation and potentially tissue repair
• Still considered somewhat experimental for TMJ disorders

3. Surgical Interventions

Reserved for severe cases that haven’t responded to conservative and minimally invasive approaches:

a) Arthroscopy:

• Minimally invasive surgical procedure
• Allows direct visualization of joint structures
• Can address adhesions and disc position in some cases
• Lower morbidity than open joint surgery

b) Disc Repositioning/Repair:

• Open joint procedure to reposition or repair the disc
• Indicated in specific cases where disc integrity can be restored

c) Joint Reconstruction:

• For advanced degenerative changes
• May involve custom joint prostheses
• Significant procedure with longer recovery time

d) Total Joint Replacement:

• Last resort for end-stage disease
• Reserved for cases with significant anatomical changes and functional limitations
• Not commonly needed for most TMD patients

Can Degeneration Be Reversed or Stopped?

This is an excellent question:

1. Reversal of Degenerative Changes:

   • True reversal of established structural changes is generally not possible
   • However, the progression can often be slowed or halted
   • The body’s adaptive capacity is remarkable, often developing a “functional adaptation”

2. Biological Response:

   • Reducing inflammation and mechanical stress allows for biological adaptation
   • Remodeling of joint surfaces can create a more compatible relationship
   • Fibrosis can stabilize the joint despite disc displacement

3. Functional Improvement:

   • Many patients achieve significant functional improvement and pain reduction
   • Even when imaging shows persistent structural changes
   • Function often improves more dramatically than structure

Multidisciplinary Approach

For your specific situation, I recommend:

1. Team-Based Care:

   • TMD specialist dentist/orofacial pain specialist
   • Physical therapist with TMJ expertise
   • Pain management physician if needed
   • Behavioral health support for pain coping strategies

2. Phased Treatment Plan:

   • Begin with least invasive approaches
   • Allow adequate time to evaluate response (typically 4-6 weeks per intervention)
   • Add interventions sequentially rather than simultaneously to evaluate efficacy

3. Regular Monitoring:

   • Tracking pain levels, jaw mobility, and function
   • Periodic reassessment of treatment efficacy
   • Adjusting approaches based on response

Specific Recommendations for You

Given your age, duration of symptoms, and MRI findings, I would suggest:

1. Initial Phase (0-3 months):

   • Comprehensive physical therapy program (2x weekly for 4-6 weeks)
   • Properly designed stabilization splint (worn primarily at night and during stress)
   • Anti-inflammatory medication protocol (scheduled rather than as-needed for 2-3 weeks)
   • Self-management techniques (thermal therapy, gentle exercises, stress reduction)

2. Secondary Phase (if needed):

   • Consider arthrocentesis with hyaluronic acid injection
   • Targeted trigger point therapy for associated muscle pain
   • Adjustment of oral appliance based on response

3. Maintenance Phase:

   • Long-term management with splint therapy
   • Periodic physical therapy “tune-ups”
   • Self-management strategies
   • Regular monitoring of joint status

I want to reassure you that most patients with your condition achieve significant improvement without needing major surgical intervention. The key is a methodical, patient-centered approach that addresses both the physical and psychological aspects of TMD.

Would you like more specific information about any particular treatment option? I’m also happy to discuss realistic expectations for improvement and timelines for each phase of treatment.

Further Reading and Resources

For more information on related topics, you might find these resources helpful:

• Understanding TMD: Beyond the Joint
• Physical Therapy Approaches for TMJ Disorders
• Self-Management Strategies for TMD
• TMJ Splint Therapy: What to Expect