Transcript Evaluation & Treatment of Temporomandibular Joint Dysfunction

Evaluation & Treatment of
TMD
Presented by:
Christy Dauner, OTR
Laurie Applebee, PT
Susan Vaughn, MS, OTR
Learning Objectives
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Identify TMD risk factors and related diagnoses
Differentiate joint and muscle disorders
Understand goals of Occupational Therapy for
TMD
Understand OT treatments for TMD and muscle
disorders
Perform assessment and treatment approaches
for TMD
Disorders of the TMJ
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Myofascial Dysfunction
Internal Derangement
Capsulitis
Subluxation
Arthritis
Risk Factors for TMD
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Trauma such as blow to the jaw, whiplash injuries, MVA,
dental work, opening the mouth too wide or for too long,
prolonged chewing
Oral parafunctional habits such as clenching and bruxism
that place continued strain on the masticatory system
Malocclusion causes bite instability or functional
interference during chewing that places postural strain
on the masticatory system
Stressful life events can trigger parafunctional habits and
muscle guarding/tension
Emotional factors such as depression or anxiety
decreases the ability to cope with pain and can increase
parafunctional habits.
TMJ Evaluation
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History & Symptoms (referred pain)
Functional Limitations
Tests, Measures & Palpation
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AROM (active/passive incisal opening, lateral
excursion, and protrusion)
PROM – scissor stretch
TMJ Noise
Muscle Palpation
Differential Diagnosis
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Scissor stretch test: if opens further muscular, if not - internal derangement
Clench test: bite down on tongue
depressor for 10 – 15 seconds. Pain on
same side – muscle, opposite side – joint
“S” vs. “C” curve with opening
Occupational Therapy
Goals for TMD
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Increase ROM to >40mm
Decrease pain
Teach joint protection (decrease parafunctional
habits, limited opening)
Improve function (eating, yawning, DDS visit
tolerance, oral hygiene, talking, sleep, work)
HEP independence
Neutral posture (head on neck, jaw, scapular
position, TUTA)
Myofascial Pain Dysfunction
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Most common disorder
Referred muscle pain
Muscle pain aggravated by jaw function or
parafunction
HA’s
Tenderness of muscles w/o mechanical
symptoms
Loss of motion or painful motion
Myofascial Pain Dysfunction
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Caused by an underlying related disorder
– malocclusion, arthritis, internal
derangement, poor posture
Education is key! – posture, parafunction,
stress management
Often chronic and cyclical
Often a myofascial component with all
diagnoses
Myofascial Dysfunction
Myofascial contributors may include:
 * Lateral pterygoid
* Medial pterygoid
* Temporalis
* Masseter
* Digastrics
* Muscles of the cervical spine
Lateral Pterygoid
Origin: Lateral Pterygoid Plate of Sphenoid
Insertion: Condylar Neck, Ramus of Mandible and Disc
TMJ Muscles – Lateral Pterygoid
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#1 myofascial source of pain
Due to attachment to disc it can cause
disc and jaw to be unable to return to
normal resting position and cause clicking
or popping.
Malocclusion of teeth/missing teeth
Referral pattern – zygomatic arch,
TMJ
Medial Pterygoid
Origin: Inner Surface of Lateral Pterygoid Plate
Insertion: Ramus of Mandible by the Angle
TMJ Muscles – Medial Pterygoid
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Stuffiness in ear
Swallowing difficulty as restriction in
protrusion of jaw
Referral pattern – posterior mandible, mouth,
below and behind TMJ including internal ear – not
teeth
Temporalis
Origin: Temporal Fascia, Superior to Zygomatic Arch
Insertion: Coronoid Process of Mandible
TMJ Muscles - Temporalis
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Significant postural muscle (the only time
it isn’t working is when you’re lying
supine)
Perpetual clenching
Referral pattern – lower jaw, molar teeth and gum,
maxilla, lower portion of mandible, temple
eyebrow and external ear
Masseter
Origin: Zygomatic Arch
Insertion: Mandibular Angle and Ramus
TMJ Muscles - Masseter
“Sinusitis”
Referral pattern - temple, along
eyebrow, behind eye or upper
teeth
Digastrics
Origin: Mastoid Notch (posterior), Symphysis of Mandible
(anterior)
Insertion: Join by a Common Tendon to the Hyoid Bone
TMJ Muscles - Digastrics
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Rarely in spasm due to forward head
posture (stretch weakness)
Referral pattern – behind mandible
toward back of ear, lower incisors
Cervical Spine Muscles
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Form stable base for TMJ on which to
work
Poor posture – condyle rotates backward –
change of biomechanics
Referral pattern from the cervical spineTemporal Headaches, SCM
Assess for tension in upper traps,
scalenes, and SCM
Parafunctional Behaviors
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Gum/candy chewing (chewing limited to 15 – 20
minutes/day!) – including chewing on one side
Clenching/bruxing/grinding
Leaning on chin/jaw
Biting nails, pencils, cheeks
Sleep position
Caffeine use
Musical instruments
Mouth breathing
Phone cradling
Treatment – Myofascial Pain
Dysfunction
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Modalities: US - 1.0 – 1.2 w/cm2, 3 MHz, x5 minutes to
joint or muscle, heat, electrical stimulation
Manual Therapy – joint mobs/distraction, MFR –
including upper cervical region
HEP/Lifestyle changes
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Tongue positioning (TUTA)
Self-joint distraction &/or MFR
Eliminating parafunctional behaviors
Postural instruction
Conjunction with splint therapy &/or counseling (Referral
to psychology for CBT as needed for stress and anxiety
management)
Resting Joint Position
Capsule – anterior/posterior only
Normal Joint Motion
Internal Derangement
Disc Disorder
Internal Derangement
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Disc held in place by collateral ligaments and
posterior ligament, w/ movement dictated by
lateral pterygoid
Click, pop, lock
Pain at joint
“S” shaped opening/closing to reposition jaw
Eye pain
History of trauma
Treatment – Internal Derangement
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Modalities: Iontophoresis, electrical stimulation, cold –
ice massage
Manual therapy – Joint distraction
Joint protection techniques: Limit motion to no noise,
soft food diet or chewing behaviors
Home exercise instruction
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Change parafunctional behaviors
Self joint distraction techniques
Tongue positioning for relaxation (TUTA)
Postural instruction and controlled
opening/neuromuscular re-education
Treatment - Other
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Capsulitis
Usually a result of another disorder unless post
surgery
 Modalities, MT and HEP
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Subluxation
Excess opening (>40 mm)
 Usually a component of myofascial pain
dysfunction, and treated as this, with addition
of stab exercises and controlled opening
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Treatment - Other
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Arthritis
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Generalized joint pain and inflammation
Usually seen in conjunction w/ other Dx
Joint protection, rest
Stretching, therapeutic exercise
Modalities (cold vs. heat, pulsed US,
phono/iontophoresis, E-stim)
Intervention: Dentist
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Assess occlusion
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Parafunctions of clenching/bruxing
Malocclusions
Pressure on back teeth activate temporalis an
superior head of lateral pterygoid, anterior
teeth activate masseters
Lab - Evaluation
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AROM (Therabite)
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Active Incisal Opening (Normal 40-60 mm)
Passive Incisal Opening (Normal 42-62 mm)
Lateral Excursion (Normal >7 mm)
Protrusion (Normal > 7 mm)
Lab - Evaluation
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TMJ Palpation/Observation
Quality of Motion:
Smooth/Rigid/Jerky/Guarded/Fasciculation/
Thrusting
 TMJ Noise: Opening Click, Closing Click,
Reproducible
 Visually Assess Opening (S or C Shaped Curve)
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Lab
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Muscle Palpation
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Medial Pterygoid (elevation, protrusion, and lateral
deviation to opposite side)
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Place index finer on muscle at inside of bottom teeth in
mouth. Place opposite thumb under jaw line below ear.
Apply pressure to muscle as if to touch finger and thumb.
Move along gum line until reach incisors in front. Hold until
relaxes 1-2X/day
Lateral Pterygoid (elevation, protrusion, and lateral
deviation to opposite side)
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Place index finger inside mouth, under cheek bone. Point
finger up and towards opposite eye. Apply pressure to
muscle until it relaxes. To check positioning of finger,
actively move jaw in opposite direction and muscle will
contract under finger. Hold until relaxes 1-2X/day
Lab
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Manual Therapy
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Trigger point release
Joint distraction
Place thumb on back, bottom molar and wrap
fingers under jaw
 Press down as you lift on jaw in scooping motion
 Do NOT pull jaw forward
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Thank You
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Feel free to contact Christy at 952-908-2567 or
at [email protected] with questions.
PDR Clinic Locations: Edina, Burnsville,
Maplewood, Burnsville, Chanhassen
Specializing in the treatment of chronic neck,
back and TMJ pain.